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

 We decided that the Plan does not have to pre-approve a total electric hospital bed.  You asked the Plan to pre-approve these services. You say that you can't lift your legs to prop them up while sleeping. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.   While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer (J1439).  You asked the Plan to pre-approve Injectafer. You say that Injectafer is medically necessary. The Plan denied your request. The Plan says a trial of Venofer and Infed is required before alternatives can be considered.  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 Injectafer. Our reviewer says that Injectafer is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs or any reason they would be unsafe or ineffective.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer (J1439).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions per day (G0424).  You asked the Plan to pre-approve the pulmonary rehabilitation visits. You say that the services are medically necessary. The Plan denied your request. The Plan says the benefits has been exhausted as the records show that the enrollee has already received 71 pulmonary rehabilitation therapy sessions.  The Plan must follow Medicare rules. Medicare rules say plans must pay for a medical service or item if regular Medicare would pay for it.  We looked at this physician's review, the file, and Medicare rules. The records show that the enrollee completed 34 Pulmonary Rehabilitation Therapy sessions in 2019 and 37 Pulmonary Rehabilitation Therapy sessions in 2021 with the last session as being completed in September 2021. Based on this information, we decided that Medicare rules for coverage of the pulmonary rehabilitation visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions per day (G0424).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee on August 6, 2021.  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 there needs to be a referral from the primary care physician.  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 outpatient mental health services provided to the enrollee on August 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a low dose computed tomography (LDCT) scan for lung cancer screening.  You asked the Plan to pay for the LDCT scan. You say that this service was medically necessary. The Plan denied your request. The Plan says this service is only covered once per year.  The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.   We reviewed the file and the Medicare rules. We find that the enrollee previously had a LDCT scan on January 26, 2021. This service is only covered once annually. Therefore, we decided that the Plan does not have to pay for a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the interrogation device evaluations provided by an out-of-network provider on May 12, 2021.  You asked the Plan to pay for the interrogation device evaluations. The Plan denied your request. The Plan says the provider that performed these services is not in-network and in-network providers were available.    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 interrogation device evaluations provided by an out-of-network provider on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0667, E0651) provided on April 20, 2021.  You asked the Plan to pay for the pneumatic compression device. You say that the items were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized and were provided out-of-network.  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 at issue in this appeal. The Plan did not pre-approve the items 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 a pneumatic compression device (E0667, E0651) provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of subcutaneous cardiac rhythm monitor, including programming (33285).  You asked the Plan to pre-approve the implantable ambulatory event monitor. You say that the requested services should be approved using the attached medical record and supporting documents. The Plan denied your request. The Plan says it is not reasonable or necessary for the enrollee to have an implanted device without failing standard external monitoring.  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 implantable ambulatory event monitor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR (insertable loop recorder). In summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this enrollee'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 the implantable ambulatory event monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of subcutaneous cardiac rhythm monitor, including programming (33285).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a left ventricular assist device (LVAD) for the enrollee.  You asked the Plan to pre-approve the device. You say that the doctor needs to confirm ostial left anterior descending artery critical stenosis. The Plan denied your request. The Plan says medical necessity has not been met, as the records do not show that the procedure is considered high risk.  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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's left ventricular ejection fraction is 60%, and the enrollee does not have NYHA class IV heart failure. As such, the guidelines for placement of this device in this setting are not met. In summary, there is insufficient documentation to support the medical necessity for LVAD placement in this enrollee'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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a left ventricular assist device (LVAD) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure.  You asked the Plan to pre-approve the Intracept procedure. You say that this procedure fills a treatment gap for patients that do not receive adequate relief from traditional conservative methods. You say that the Intracept procedure is medically necessary, and the procedure should be approved. The Plan denied your request. The Plan says unproven and not medically necessary procedures are 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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental, and more research is needed.     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 the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).  You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the requested CGM have not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the maxillary partial denture (D5213) provided on August 27, 2021.  You asked the Plan to pay for the maxillary partial denture. You say that both pre-authorizations were approved, and you would like to know why this service is being denied. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that you received this service less than 60 months ago.  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, partial dentures are limited to once per 60 months. The record shows that you received a partial denture on March 26, 2021 and your partial dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the maxillary partial denture (D5213) provided on August 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the brain imaging, positron emission tomography (PET) (78608).  You asked the Plan to pre-approve the PET scan. You say that your doctor had a CT scan to try to rule out Alzheimer's but had deemed that the only way to know for certain is with a PET scan. This is necessary so you can take the proper steps if you are developing this disease. The Plan denied your request. The Plan says the records do not support a clinical presentation suggestive of the enrollee having both Alzheimer's disease and frontotemporal dementia as required by the Medicare rules.  The Plan must follow Medicare rules. Medicare rules say that PET scans 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 the PET scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee is presented with mild cognitive impairment, scored 28/30 on the Mini-Mental Status Exam (MMSE). An MRI of the brain demonstrated mild cerebral atrophy and small vessel ischemic changes. There are no documented symptoms or concerns for an alternative diagnosis to dementia, such as frontotemporal dementia (FTD). There are no reported symptoms to suggest the presence of FTD such as social disinhibition, awkwardness, difficulties with language, or loss of executive function. Also, per the medical records, the enrollee is not participating in a CMS approved controlled trial for evidence development. The review has determined that the enrollee does not have an indication for which a PET Scan can be covered 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 the PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the brain imaging, positron emission tomography (PET) (78608).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (76770) provided September 17, 2021.  You asked the Plan to pay for the radiology services. You say that the radiology services were medically necessary. The Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed and 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. In this case, we have confirmed that code 76770 has a bundled relationship with code 93976. 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 radiology services (76770) provided September 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the esophagogastroduodenoscopy coded 43235 provided on June 3, 2020.  You asked the Plan to pay for the esophagogastroduodenoscopy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are 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. In this case, we have confirmed that code 43235 is a column II code to column I code 43237. 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 esophagogastroduodenoscopy coded 43235 provided on June 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient mental health services (90833, 99213) provided on July 9, 2021 to August 6, 2021.  You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.  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 services 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 these services.  Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90833, 99213) provided on July 9, 2021 to August 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (83880, 85025, 80053, 85014, 85018, 85025, 84134, 84443, 80053) provided on April 9, 2021, to April 30, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that based on the information provided from the Centers for Medicare & Medicaid Services (CMS) waivers and the coronavirus (Covid-19) response, you would like the Plan to review the claim. You also say that you have submitted supporting documents. The Plan denied your request. The Plan says that this provider is not a network provider with the Plan and they have also determined that these services are 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 laboratory services (83880, 85025, 80053, 85014, 85018, 85025, 84134, 84443, 80053) provided on April 9, 2021, to April 30, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (70544) provided September 23, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed.  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 70544 is a column II code to column I code 70551. 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 radiology services (70544) provided September 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound, abdominal, real time with image documentation; complete (76700) provided September 15, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that ultrasounds do not involve radiation and should not have a radiology copayment. The Plan denied your request. The Plan says the copayment was applied 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 $175 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility.  You have been asked to pay a $129.49 copayment for the ultrasound. The ultrasound falls within the Outpatient diagnostic tests and therapeutic services benefit category. Radiological services use medical imaging technology to diagnose and treat disease. Some types of radiology use radiation while other do not. The Plan contract clearly shows that ultrasounds are correctly categorized as a radiological diagnostic service. This means that you have been asked to pay less than or equal to 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 ultrasound, abdominal, real time with image documentation; complete (76700) provided September 15, 2021.   Your complaint about issues with receiving communication from the Plan, the way diagnostic services are categorized, differences in the cost of services from year to year, and complaints about the network provider are not valid appeals for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.