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

We decided that the Plan does not have to pay for the laboratory services provided on March 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 services provided on March 10, 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 Genesight Psychotropic panel provided on March 16,
2021, billed with code 81479.

You asked the Plan to pay for the Genesight panel. You say that this is covered by Medicare. The Plan denied your request. The Plan says this is not supported by the literature.

The Plan must follow Medicare rules. Medicare rules say that the present evidence does not clearly demonstrate that PGx testing, such as this Genesight panel, for the purpose of medication selection offers a benefit over selection of medications based on contemporary evidence-based medication selection protocols. Therefore, we decided that the Plan does not have to pay for the Genesight Psychotropic panel provided on March 16, 2021, billed with code 81479.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-SCC testing rendered on January 20, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
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 these services. Our reviewer says that the services were not medically necessary.
Our physician reviewer found the enrollee has a diagnosis of well-differentiated squamous cell carcinoma on her forehead. The documentation is insufficient to demonstrate that the DecisionDx-SCC testing was medically reasonable and necessary for the enrollee in this case. 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 pay for the DecisionDx-SCC testing rendered on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of nails by any method (11721) and paring or cutting of benign hyperkeratotic lesion (eg, corn or callus) (11056) provided April 26, 2021.

You asked the Plan to pay for the podiatry services. You say that you are requesting reconsideration of the denied claim. You have attached the coding edits for 2021 as a reference. You have also attached the physician's office note and the Plan's reimbursement policies for reference. The Plan denied your request. The Plan says routine foot care services is not a covered benefit.

The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. 

Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the podiatry services have not been met.
Therefore, we decided that the Plan does not have to pay for the debridement of nails by any method (11721) and paring or cutting of benign hyperkeratotic lesion (eg, corn or callus) (11056) provided April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device.

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. Medicare rules say that replacement durable medical equipment is covered in the case of irreparable damage or when the equipment as exceeded the reasonable lifetime period of five years. 

We looked at the file and Medicare rules. The file shows that the enrollee's current CPAP device is not irreparable damaged or more than five years old. 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 replacement continuous positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network hematologist.

You asked the Plan to pre-approve these services. You say that this doctor can treat you. The Plan denied your request. The Plan says the services are available from network providers.

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 a referral to an out-of-network hematologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5298) purchased on April 25, 2021.

You asked the Plan to pay for hearing aids. You say that you were not told you needed to use a Plan provider.
The Plan denied your request. The Plan says the requirements for coverage have not been met.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when they are provided by Plan hearing providers.

We looked at the file and the Plan's rules. The record shows that the hearing aids at issue were not purchased
from a Plan provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids
have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5298)
purchased on April 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan provided on May 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the CT scan. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.

Therefore, we decided that the Plan does not have to pay for CT scan provided on May 26, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
You asked the Plan to pre-approve the special supplemental benefits for the chronically ill. The Plan denied your request. The Plan says you do not meet the required criteria that make you eligible for these special supplementary benefits.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the special supplemental benefits for the chronically ill have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the professional component of the immunofixation electrophoresis provided on April 27, 2021, billed with code 86334-26.
You asked the Plan to pay for the professional component of the immunofixation electrophoresis. You say that this was correctly billed and should be paid. The Plan denied your request. The Plan says this was billed with an inappropriate modifier.
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 it is not appropriate to report modifier -26 to bill for the professional component of this service. 86334 is payable only on the Clinical Laboratory Fee Schedule which does not allow for reporting of professional/technical components of this code.
Based on this information, we decided that Medicare rules for coverage of the professional component of the immunofixation electrophoresis have not been met. Therefore, we decided that the Plan does not have to pay for the professional component of the immunofixation electrophoresis provided on April 27, 2021, billed with code 86334-26.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory work provided on May 17, 2021.

You asked the Plan to waive the deductible for the laboratory work. You say that you have Medicaid cost share protection and that you do not have a deductible. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $203 deductible which applies to laboratory services. 

The laboratory work you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible which applies to laboratory services.

This cost sharing is a contractual obligation that had not been met at the time laboratory work provided on May 17, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory work provided on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia services provided on December 7, 2020, billed with code 99100.
You asked the Plan to pay for the special anesthesia services. You say that payment should be made for these services. The Plan denied your request. The Plan says payment was approved for all codes except 99100 which is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 99100 has a status indicator of "B" in the Physician Fee Schedule. This means that payment for this is always bundled in payment for other services.
Based on this information, we decided that Medicare rules for coverage of the special anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia services provided on December 7, 2020, billed with code 99100.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF admission. You say that you can barely walk and cannot take care of yourself. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have a pelvic and lumbar fracture. You had stable vital signs. You required modified independence to stand-by assistance with functional mobility including walking to 150 feet with a rolling walker. The documentation does not support that you require the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that you require skilled nursing or skilled therapy services on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J7323).

You asked the Plan to pre-approve Procrit. You say that this medication is medically necessary. The Plan denied your request. The Plan says Procrit is not medically reasonable or necessary for the enrollee.

The Plan follows Medicare rules. Medicare rules say that erythropoiesis stimulating agents (ESA) treatment is not reasonable and necessary for beneficiaries with certain clinical conditions.

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 Procrit. Our reviewer says that Procrit is not medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee has chronic myelomonocytic leukemia. The reviewer found that the noted condition is excluded from coverage according to the coverage criteria. Therefore, the reviewer found that the requested medication is 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 Procrit have not been met. Specifically, the record shows that the enrollee's condition is excluded from coverage. Therefore, we decided that the Plan does not have to pre-approve Procrit (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.

You asked the Plan to pre-approve a portable ventilator. You say that without this device your health would decline. The Plan denied your request. The Plan says the requested portable ventilator is not medically necessary.

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 a portable ventilator. Our reviewer says that the documentation does not support that the requested portable ventilator is medically reasonable or necessary. Our physician reviewer found you have a diagnosis of chronic obstructive pulmonary disease (COPD). You were recently hospitalized with hypercapnic and hypoxic respiratory failure requiring intubation. Chronic narcotic therapy may be contributing to hypoventilation.

You may benefit from bilevel positive airway pressure (BiPAP) at night. But Medicare does not cover a
ventilator when used as BiPAP. There is no evidence that BiPAP has been tried in the home setting. Certain
BiPAP devices can provide the AVAPS (average volume-assured pressure support) mode of support.
Therefore, you do not meet criteria for the requested device.

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 portable ventilator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a portable ventilator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiogram and duplex scans provided on January 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the echocardiogram and the duplex scans. You say that an authorization was requested and received for this date of service. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the echocardiogram and the duplex scans provided on January 26, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan provided on April 15, 2021.

You asked the Plan to waive the copayment for the CT scan. You say that you would like the plan to reconsider your request. The Plan denied your request. The Plan says you received a CT scan on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $125 copayment for Outpatient diagnostic tests. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a CT scan on April 15, 2021. You have been asked to pay a $125 copayment for the CT scan. The CT scan 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 copayment for the computed tomography (CT) scan provided
on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup, including any pins when required (D2950).

You asked the Plan to pre-approve the crown and core buildup. You say that you were advised that the crown would be covered. The Plan denied your request. The Plan says these services are not covered under your benefit 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 a crown (D2740) and core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) and a maxillary partial denture (D5213).

You asked the Plan to pre-approve the core buildup and maxillary partial denture. The Plan denied your request. The Plan says the core buildup is not a covered benefit. The Plan also says that the maxillary partial denture exceeds the benefit allowance.

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 core buildup, including any pins when required (D2950) is not among those covered under this benefit. The contract says that maxillary partial denture (D5213) is limited to 1 of either codes D5110, D5211, D5213, D6110 or D6112 once per 5 calendar years. The record shows that you received a maxillary partial denture (D5213) on January 30, 2021 and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) and a maxillary partial denture (D5213).