Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for actinotherapy (ultraviolet light) (CPT code 96900) provided
to the enrollee on May 25, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the clinical value and effectiveness of actinotherapy (ultraviolet light), in the setting of back pain
have NOT been demonstrated in the peer-reviewed literature.
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 pay for the service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no documentation that the enrollee has psoriasis or any condition that would be
appropriately treated with ultraviolet light. The clinical value and effectiveness of Actinotherapy (ultraviolet
light), in the setting of back pain have not been demonstrated in the peer-reviewed literature. The review has
determined that the items/services at issue in this case are not medically reasonable or necessary.
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 service have not been met. Therefore, we decided that the Plan does not
have to pay for actinotherapy (ultraviolet light) (CPT code 96900) provided to the enrollee on May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a resin-based composite (D2332) provided by a participating
provider on December 17, 2020.
You asked the Plan to pay for a resin-based composite. You say that you believe the Plan should pay for this.
The Plan denied your request. The Plan says the rendered dental services were not a covered benefit.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-
based composite (D2332) provided by a participating provider on December 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says the physician will not be furnishing the Prolia, therefore, this drug is
not covered under the enrollee's Part B benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Prolia.
Benefits for Prolia 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablations (CPT code(s): 64635 and
64636).
You asked the Plan to pre-approve the services. You say that you were not notified of the denied services until
the date of the service. The Plan denied your request. The Plan says you exhausted your benefit frequency limit
listed in the LCD.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. Review of the file shows that you
already had at least 2 ablation sessions to this spinal region in the last 12 months. Therefore, we decided that
the Plan does not have to pre-approve radiofrequency ablations (CPT code(s): 64635 and 64636).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (81407, 81408, 81410, and 81411) provided on April 27, 2021.  You asked the Plan to pay for the laboratory 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  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (81407, 81408, 81410, and 81411) provided on April 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on September 2, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you were in no condition to either have
these drugs available or administer them to yourself because of the heart attack. You also say that you believe
these self-administered drugs should be covered under your health plan. The Plan denied your request. The
Plan says the provided drugs are self-administered medications and are not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided on September 2, 2021.
Benefits for the self-administered drugs 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 reimburse for the out of country medical services provided on
September 25, 2020.
You asked the Plan to reimburse for the out of country medical services. You say that you were diagnosed with
Coronavirus and decided to leave the country to stay with a sibling. You state your symptoms worsened and
caused you to seek medical attention. The Plan denied your request. The Plan says you provided a copy of
laboratory results and a note from the attending doctor for your out of country reimbursement request. The Plan
states they asked you if there are any other clinical records from the provider, but you stated that you have no
other documents to provide.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the out of country medical services have not been met. Insufficient
medical documentation was received to justify the medical necessity and reimbursement. Therefore, we
decided that the Plan does not have to reimburse for the out of country medical services provided on September
25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill
or critically injured patient; first 30-74 minutes (CPT code 99291) provided to the enrollee on June 8, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the service is not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. We find that CPT code 99291 is not supported
in the medical record. Based on this information, we decided that Medicare rules for coverage of the service
have not been met. Therefore, we decided that the Plan does not have to pay for critical care, evaluation and
management of the critically ill or critically injured patient; first 30-74 minutes (CPT code 99291) provided to
the enrollee on June 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute gastrointestinal blood loss imaging (CPT code 78278-26-76) provided to the enrollee on April 7, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  The provided reports show that one exam was performed and that an addendum/correction was placed in the note to correct the dosage of radiopharmaceutical. This correction to the first report does not constitute a second exam report.    Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for acute gastrointestinal blood loss imaging (CPT code 78278-26-76) provided to the enrollee on April 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Hymovis.  You asked the Plan to pre-approve Hymovis. You say that you are appealing with supporting records. 

The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Orthovisc, Synvisc, and Synvisc-One before it will approve Hymovis.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  

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 Hymovis. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Hymovis. Our physician reviewer found the record does not show that the enrollee has tried and failed the Plan's preferred drugs of Orthovisc, Synvisc, and Synvisc-One. The documentation does not support that these drugs would likely be less effective and/or have adverse effects for the enrollee.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Hymovis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
You asked the Plan to pre-approve the home ventilator. You say that this is to be used for the treatment of
COPD with chronic respiratory failure (CRF). The Plan denied your request. The Plan says the request for a
home mechanical ventilator set in TTV-VAPS mode that could be delivered by bilevel positive airway pressure
(BiPAP) is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 home ventilator. Our physician
reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive
pulmonary disease. The provided primary source documentation does not contain sufficient detailed
information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP
machine with average volume assured pressure support (AVAPS) capability. The plan has indicated such a
device is available. The elements of the coverage criteria are not satisfied. The requested service cannot be
recommended.
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 home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 9, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that the service was medically necessary. The Plan denied your request. The Plan says the service was not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found it was not expected that the patient would require hospital services that would cross two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing (CPT code 88305) provided to the
enrollee on June 11, 2021, by an out-of-network provider.
You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied
your request. The Plan says this provider is out-of-network, the services were not referred by a network
provider, and the services were not urgent or emergent, nor were they approved in advance.
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. 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 the laboratory testing (CPT code 88305) provided
to the enrollee on June 11, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the full mouth debridement (D4355),
pre-diagnostic adjunctive test (D0431), complete series x-ray (D0210), and comprehensive oral evaluation
(D0150) provided on June 14, 2021.
You asked the Plan to pay an additional amount for the dental services. You say that the dental office you
received the services at was given to you by the Plan. You say that because of this, you are not paying this bill.
You also say that The Plan denied your request. The Plan says out of network dentists may bill you for any
amount greater than what the Plan pays. The Plan also says that pre-diagnostic adjunctive test is not listed as a
covered service.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the provider in this case is out of
network. While dental care received out of network, they are subject to a higher cost sharing amount. Out of
network providers may bill you for any amount greater than what the Plan pays. This is a contractual obligation
you agreed to when you enrolled in the Plan's dental coverage. Additionally, the pre-diagnostic adjunctive test
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay an
additional amount for the full mouth debridement (D4355), pre-diagnostic adjunctive test (D0431), complete
series x-ray (D0210), and comprehensive oral evaluation (D0150) provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for VEP checkerboard or flash testing, central nervous system
except glaucoma, with interpretation and report (CPT code 95930) and short-latency somatosensory evoked
potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous
system; in upper and lower limbs (CPT code 95938) provided to the enrollee on April 30, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says incorrect CPT codes being submitted when there is a more appropriate code available
for the services provided.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Incorrect CPT codes being submitted when there is a more appropriate code available for the services provided.
The Plan states the enrollee meets medical necessity criteria for the performed services. The health plan states
they will approve the appropriate CPT code 95861 if submitted. 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 VEP checkerboard or flash testing, central nervous system except glaucoma, with interpretation
and report (CPT code 95930) and short-latency somatosensory evoked potential study, stimulation of any/all
peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs (CPT code
95938) provided to the enrollee on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (CPT code 90715) and immunization administration (CPT code 90472) provided on March 23, 2021.

You asked the Plan to pay for the services. You say that your primary care physician advised you to get your vaccine, not knowing it was not going to be covered by your plan. The Plan denied your request. The Plan says the services are not covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. 

Diagnoses billed on the claim for 90715 include Z23 (Encounter for immunization). This diagnosis is not considered an appropriate diagnosis for a tetanus vaccine as described in the referenced Medicare Benefit Policy Manual. Your 2021 EOC states, "Part B covers influenza vaccine, pneumococcal vaccine and Hepatitis B vaccine for intermediate and high-risk beneficiaries. Medicare Part B plan covers vaccines that are necessary to treat an injury or illness." Furthermore, Code 90472 is being upheld because CPT code 90715 is not covered. Therefore, we decided that the Plan does not have to pay for tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (CPT code 90715) and immunization administration (CPT code 90472) provided on March 23, 2021.

Benefits for the services 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 pre-approve the office visit (CPT code 99204) to be provided by out-of-network providers.
You asked the Plan to pre-approve the office visit. You say that the cancer has spread to your liver. You state the requested provider can give you a appointment immediately. The Plan denied your request. The Plan says this provider is not a network provider and the service needed is available within the network. The Plan states that you have an appointment on October 21, 2021, so the allegations of an inability to obtain an appointment are not true.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. 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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit (CPT code 99204) to be provided by out-of-network providers.