Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 29, 2020, to October 28, 2020.

You asked the Plan to pay for home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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 was not submitted with one of three required "Q" codes to show the location the service was provided. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 29, 2020, to October 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) report (93042)
provided on June 18, 2021.
You asked the Plan to pay for the rhythm ECG report. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 93308
and 93042.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93042
is a column II code to column I code 93308. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) report (93042) provided on
June 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the individual psychotherapy services (90832) provided October 8,
2021.
You asked the Plan to pay for the psychotherapy services. You say that the enclosed medical records clearly
reflect the medical necessity for the services rendered. The Plan denied your request. The Plan says that the
service is not supported without required documentation.
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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of psychotherapy services have been met. The submitted claim includes a referring provider for the
services at issue. Documentation of a physician consultation does not apply when the physician has referred the
beneficiary to the clinical psychologist. Therefore, we decided that the Plan has to pay for the individual
psychotherapy services (90832) provided October 8, 2021.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex placement procedure (22869, 22870).
You asked the Plan to pre-approve a Vertiflex placement procedure. You say that the requested procedure is a
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not
been met because the requested procedure is experimental/investigational.
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 a Vertiflex placement procedure. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found that the Vertiflex device is experimental. More research is needed to demonstrate
the safety and efficacy of the requested procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Vertiflex placement procedure have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Vertiflex placement procedure (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on September 3, 2021.
You asked the Plan to reimburse you for eyeglasses. The Plan denied your request. The Plan says the member
used a non-participating provider; therefore, the member would not be eligible for reimbursement.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services when provided by a network optical provider.
We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by a network
optical provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not
been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on
September 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the subcutaneous tissue debridement
(11042) provided on August 19, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $225
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including
but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a $225 copayment for the Medicare-covered surgery provided at an outpatient
hospital. 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 copayment for the subcutaneous tissue debridement (11042)
provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network
(OON) provider on September 21, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on
September 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia and multiple myeloma. She has not tried and failed the Plan's required drug, zoledronic acid. The records do not show that the required drug would be contraindicated or less effective; therefore, Xgeva is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Visco-3.

You asked the Plan to pre-approve Visco-3. You say that this drug is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been met for the requested drug.

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 Visco-3. Our reviewer says that the requested drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the enrollee is a 75-year-old female with a history of right knee pain due to osteoarthritis of the knee. The enrollee has not trialed one viscosupplemental treatment such as Orthovisc, Synvisc or Synvisc-One. Step therapy, as outlined by the plan, requires that one of these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Visco-3 is not approved, as step criteria have not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Visco-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Visco-3.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement services provided on March 2, 2021.

You asked the Plan to waive the copayment for the wound debridement. You say that you were not in an operating room for the procedure. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

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 $350 copayment per date of service for surgery or services provided at an outpatient hospital facility.

You have been asked to pay a $350 copayment for the wound debridement. Please note that any procedure involving tissue removal (debridement) is considered surgical. The wound debridement falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 copayment for wound debridement services provided on March 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the abdominal ultrasound you had on January 21, 2021, and the non-invasive extremity study you had on January 28, 2021.

You asked the Plan to waive the copayments for the abdominal ultrasound and the non-invasive extremity study. You say that you were never advised that you would owe any copayments and you cannot afford this bill. The Plan denied your request. The Plan says you were charged these copayments 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 $50 copayment each for diagnostic radiology services in an office setting. 

You have been asked to pay a $50 copayment each for the abdominal ultrasound and the non-invasive extremity study. The abdominal ultrasound and the non-invasive extremity study fall within the diagnostic radiology services in an office setting 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 the abdominal ultrasound you had on January 21, 2021, and the non-invasive extremity study you had on January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341x4) and
periodontal maintenance (D4910).
You asked the Plan to pre-approve periodontal scaling and root planing and periodontal maintenance. You say
that you need the requested services to stop your heavy gum bleeding and dental stone problem. This will
improve your overall health. You also say that if you continue to swallow the blood and dental stones, it will
affect your heart problem as well as your mental health. The Plan denied your request. The Plan says the
requested services are not a covered benefit with your Plan.
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 pre-approve
periodontal scaling and root planing (D4341x4) and periodontal maintenance (D4910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone graft in conjunction with periradicular surgery - per tooth, single site (D3428), interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820), and removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm (D7451) provided October 12, 2021.

You asked the Plan to pay for the bone graft, interim upper partial denture and removal of benign odontogenic cyst or tumor. You say that you don't understand why the services are not covered. The Plan denied your request. The Plan says these services are not covered under your benefits.

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 the bone graft in conjunction with periradicular surgery - per tooth, single site (D3428), interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820), and removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm (D7451) provided October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network
(OON) provider on October 13, 2020.
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 laboratory services rendered by the out-of-network (OON) provider on
October 13, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home visit for custodial care.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that custodial care is not covered.
We looked at the file and Medicare rules. The requested services are for custodial care. Based on this
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we
decided that the Plan does not have to pre-approve a home visit for custodial care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a CardioMEMS device.  You asked the Plan to pre-approve a CardioMEMS device. You say that the records provided support the need for the CardioMEMS device. The Plan denied your request. The Plan says multiple studies have not shown that this device has long-term benefits in treating heart failure.  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 a CardioMEMS device. Our reviewer says that a CardioMEMS device is not considered medically reasonable and necessary in this case. Our physician reviewer found the CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with congestive heart failure (CHF.) The clinical study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this patient's clinical management.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee continues to receive acute care services, and these have not been denied. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical assessment does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 14, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that the samples were sent to you to test from the ordering physician which was medically necessary for the enrollee. The Plan denied your request. The Plan says the referring provider and rendering provider are both non-participating providers without prior authorization. The services were not urgent or emergent.

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 laboratory services provided on July 14, 2021, by an out-of-network (OON) provider.