Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for glucose monitoring supplies (K0553) provided on October 24, 2020.
You asked the Plan to pay for glucose monitoring supplies. You say that these items are supported in the records. The Plan denied your request. The Plan says there is not a valid proof of delivery for the items at issue.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery. As a general Medicare rule, the date of service shall be the date of
delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. The submitted
delivery ticket shows a delivery date of October 8, 2020, but the supplies at issue were billed for October 24,
2020. The record shows that the Plan made several attempts to obtain the necessary documentation without
success. Therefore, we decided that the Plan does not have to pay for glucose monitoring supplies (K0553)
provided on October 24, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (G0483) provided to the enrollee on December 7, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (G0483) provided to the enrollee on December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the face down recovery table provided on January 6, 2021 to January 13, 2021.
You asked the Plan to pay for the face down recovery table. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the face down recovery table provided on January 6, 2021 to January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with a specialist (92004) provided on January 26, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that you had a brain injury that caused double vision. You also say that you asked the provider's office if they accept your plan and they advised they would take care of everything. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit with a specialist (92004) provided on January 26, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for add tooth to existing partial denture (D5650) provided August 13, 2021.
You asked the Plan to pay for add tooth to existing partial denture. You say that you would like reimbursement for the money you paid to the provider. The Plan denied your request. The Plan says this provider has opted out of Medicare and therefore the services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers add tooth to existing partial denture when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of add tooth to existing partial denture have not been met. Therefore, we decided that the Plan does not have to pay for add tooth to existing partial denture (D5650) provided August 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient hospital stays provided from September 19, 2020, to February 15, 2021.
You asked the Plan to waive the copayments for inpatient stays. You say that you do not know why you are receiving these bills. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $170 copayment per day for days 1 to 7 for 2020 and $150 copayment per day for days 1 to 5 for 2021 for in-network inpatient hospital care. The inpatient stay from September 19, 2020 to September 24, 2020 lasted 5 days, resulting in a copayment amount of $850. The inpatient stay from January 31, 2021 to February 15, 2021 lasted 16 days, resulting in a copayment amount of $750. Your total copayment obligation is therefore $1,600. You have been asked to pay $170 copayment per day for days 1 to 7 for 2020 and $150 copayment per day for days 1 to 5 for 2021 for inpatient stays. Inpatient stays fall within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for inpatient hospital stays provided from September 19, 2020, to February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99324), nail debridement (11720), and the nail trimming (11719) rendered by the out-of-network (OON) provider on April 7, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal.
The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay
for these services. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home
visit (99324), nail debridement (11720), and the nail trimming (11719) rendered by the out-of-network (OON)
provider on April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.

You asked the Plan to pre-approve MRI of the lumbar spine. You say that this request is medically necessary for your back pain. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve MRI of the lumbar spine. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found that you are a 67-year-old female with back pain. MRI lumbar spine was requested. You had joined a gym and her back pain started after exercising. The provided documentation, however, did not clearly describe that you have tried and failed a full course of conservative treatments including Non-steroidal anti-inflammatory drugs, physical therapy, and home stretches/exercises, nor was there objective evidence of a red flag diagnosis which warranted earlier imaging. Therefore, this request for MRI will be considered not medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS device.

You asked the Plan to pre-approve the CardioMEMS device. You say that this request should be considered medically necessary and reasonable for the enrollee's condition. The Plan denied your request. The Plan says that the requested service is considered experimental/investigational.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CardioMEMS device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the patient has New York Heart Association (NYHA) Class III heart failure with preserved ejection fraction and is on beta blockers and high dose oral diuretic regimen with recurrent and recent hospitalization for congestive heart failure (CHF). Management of his heart failure with standard medical therapy and relying on symptoms, weights and signs has not been effective in keeping him with minimal symptoms and has resulted in acute hospitalizations within the past year. CardioMEMS device monitoring in this situation can provide additional heart filling pressure data to better manage very complex regimens to optimize fluid status. Given the severe symptoms of recurrent CHF which appear very sensitive to volume loading conditions, the complexity of the medical regimen and the failure to prevent acute CHF hospitalization in this patient, use of the CardioMEMS device is reasonable and has clinical data, expert opinion, and approved Food and Drug Administration indications to back up its use in selected appropriate clinical situations like this one. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CardioMEMS device have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS device.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 27, 2020 to October 23, 2020.

You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim is missing an appropriate Q code per Medicare guidelines with the same date of service. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 27, 2020 to October 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intracept procedure (C9752, 22899).

You asked the Plan to pre-approve the intracept procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is not covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is only FDA approved for basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain of at least six months duration that has not responded to at least six months of conservative care, and is also accompanied by features consistent with Type 1 or Type 2 Modic changes on an MRI. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an intracept procedure (C9752, 22899).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the magnetic resonance imaging (MRI) provided on April 28, 2021.

You asked the Plan to waive the copay for the MRI. You say that the MRI is too expensive. The Plan denied your request. The Plan says the claim processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copay for advanced imaging services in an outpatient hospital. 

You have been asked to pay $215.54 for the MRI. Because the amount is less than the $250 copay, you were charged the lesser amount. The MRI falls within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the magnetic resonance imaging (MRI) provided on April 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care after August 3, 2021.

You asked the Plan to pre-approve inpatient mental health care. You say that inpatient mental health care continues to be medically necessary. The Plan denied your request. The Plan says the criteria for inpatient mental health care is no longer medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient mental health care. Our reviewer says that the requested inpatient mental health care is not medically reasonable and necessary. Our physician reviewer found that this 31-year-old male was admitted to acute inpatient psychiatric hospitalization on July 6, 2021, with schizoaffective disorder bipolar type. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any behavioral issues yet had auditory hallucinations that were not bothering him. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. Based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of August 3, 2021, forward, and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation and was not showing any aggressive behaviors being cooperative and compliant. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care after August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the gastroenterology treatment provided by an OON provider.

You asked the Plan to pay for the gastroenterology treatment. You say that you are not getting adequate medical care. The Plan denied your request. The Plan says a referral out of network is not medically necessary.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider at issue in this case is not a network provider with the Plan. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the gastroenterology treatment. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the medical record shows your treatment and second-opinion evaluation by an in-network physician are adequate. The record shows additional standard of care recommendations have been rendered to you.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the gastroenterology treatment have not been met. 

The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pay for the gastroenterology treatment. Therefore, we decided that the Plan does not have to pay for the gastroenterology treatment provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids, and acellular pertussis (TDAP) vaccine (90715).

You asked the Plan to pay for the vaccine. You say that the service should be covered and was medically necessary. The Plan denied your request. The Plan says this vaccine is not covered under the Part B medical benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids, and acellular pertussis (TDAP) vaccine (90715).

Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on February 26, 2021 by an outof-
network (OON) provider.

You asked the Plan to pay for the OON services. You say that the nursing home is responsible to obtain prior
authorization. The Plan denied your request. The Plan says an approved authorization was not in effect on the
date of service.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the rest home visit provided on February 26, 2021 by an out-of-network (OON)
provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive cardiovascular panel provided on January 5, 2021.

You asked the Plan to pay for the testing services. You say that the results allow the physician to make treatment decisions. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The testing services at issue were requested for screening purposes. The records do not show that the results of the testing would be used for a specific medical problem. Services provided in the absence of signs or symptoms are not covered. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive cardiovascular panel provided on January 5, 2021.