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

decided that the Plan does not have to pre-approve laser hair removal of skin graft following MOHS surgery for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is for cosmetic purposes.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 procedure. Our reviewer says that the requested services are not medically reasonable or necessary. Our reviewer found the record indicates that the enrollee underwent MOHS surgery and had a skin flap placed on her nose in 2020. The records do not indicate that the requested procedure is to repair an injury or improve function. The record does not indicate that the requested procedure is necessary for the diagnosis or treatment of an illness or injury. The elements of the coverage criteria are not satisfied. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve laser hair removal of skin graft following MOHS surgery for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on April 9, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.

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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the applicable medical history in this enrollee is hypertension and a family history of stroke. Cardiac gene variant testing has limited clinical application at present and is occasionally useful in more rare familial inherited cardiac conditions. Current AHA/ACC guidelines recommend using clinical risk factor profiles and occasionally radiologic studies (CT calcium scores) for assessing cardiovascular atherosclerotic risk and determining individual patient risk factor modification, use of lipid lowering therapies, etc based on clinical risk calculations. Guidelines also recommend that the enrollee's hypertension should be treated to goal based on clinical readings alone. Cardiac gene variant testing is therefore not currently recommended for general risk stratification and would not be considered 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for predictive screening testing provided to the enrollee on March 4, 2021.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.
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, the testing, 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 predictive screening testing provided to the enrollee on March 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit for the enrollee.
You asked the Plan to pre-approve Retacrit. You say that this is medically necessary for the patient to improve his quality of life and health. The Plan denied your request. The Plan says that the accepted use of this drug for your illness requires the member is receiving myelosuppressive chemotherapy when the anticipated outcome is palliation.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Retacrit. Our reviewer says that Retacrit is not medically reasonable and necessary for the enrollee. Retacrit is not FDA-approved for the enrollee's diagnosis. The patient is being treated with chemotherapy for curative intent and anemia is chemotherapy induced. The use of Retacrit is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Retacrit.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on April 2, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
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 testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is very limited medical history provided other than listed diagnoses. Cardiac gene variant testing has limited clinical application at present and is occasionally useful in more rare familial inherited cardiac conditions. Current AHA/ACC guidelines recommend using clinical risk factor profiles and occasionally radiologic studies (CT calcium scores) for assessing cardiovascular risk and determining individual patient risk factor modification, use of lipid lowering therapies, etc. Cardiac gene variant testing is not currently recommended for general risk stratification and would not be considered 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extraction (D7210), initial 15 minutes of deep sedation
(D9222), and the additional 15 minutes of deep sedation (D9223) provided on January 8, 2021.
You asked the Plan to pay for the dental services. You say that it is very unfair for the Plan to ask for your
money back. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare.
The Plan says that payment cannot be made for services received from providers that have opted out of
Medicare.
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, dental services that received from a
provider that has opted out of Medicare are not eligible for reimbursement. Therefore, we decided that the Plan
does not have to pay for extraction (D7210), initial 15 minutes of deep sedation (D9222), and the additional 15
minutes of deep sedation (D9223) provided on January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 22, 2021, by a nonparticipating
provider.

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 rendered by a non-participating provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. 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 office visit provided on March 22, 2021, by a
non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided January 11, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 G0483 is not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service described in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional unit of initial observation care (99220) provided on February 6, 2020.
You asked the Plan to pay for an additional unit of initial observation care. You say that this was billed correctly. The Plan denied your request. The Plan says this was previously billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that an additional unit of CPT code 99220 are not supported in the medical record. The medical record only supports one unit of CPT code 99220, which was previously billed. Based on this information, we decided that Medicare rules for coverage of an additional unit of initial observation care have not been met. Therefore, we decided that the Plan does not have to pay for an additional unit of initial observation care (99220) provided on February 6, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), trifocal lenses (V2300) and progressive lenses (V2781) provided on May 5, 2021.
You asked the Plan to pay for eyeglass frames, trifocal lenses and progressive lenses. You say that you were told by both your provider and eye surgeons that you were entitled to receive a 2nd pair of glasses after cataract surgery. They advised that you would be reimbursed $175 for the new glasses. You are also asking for reconsideration of payment. The Plan denied your request. The Plan says the provider is not part of your Plan's medical network.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from a provider who participates in the Plan's specified vision network. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The Plan covers eyewear when they are received from a provider who participates in the Plan's specified vision network. Please note, the Plan resubmitted your claim under your medical benefits and the provider listed on the claim is not a network provider with the Plan. The services were provided by an out-of-network provider without prior authorization. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, trifocal lenses and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), trifocal lenses (V2300) and progressive lenses (V2781) provided on May 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance rendered on May 18, 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 procedure code 77003 is not supported.
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, the CPT Code Manual definition of code 77003 is fluoroscopic guidance and localization of needle
or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or
subarachnoid) (List separately in addition to code for primary procedure).
We find that CPT code 77003 is not supported in the medical record. Specifically, this is an add-on code that
was not billed with a required primary procedure code. 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 fluoroscopic guidance rendered on May 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation
services (A0427, A0425) provided on May 23, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you are on a fixed income
and cannot afford this bill. You were injured at the time of service and did not know there would be a copay.
The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was
assessed in accordance with your contract.
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 $150
copayment for each Medicare-covered one-way ground ambulance transport.
You have been asked to pay a $150 copayment for the ambulance services. 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 emergency ambulance transportation services (A0427, A0425) provided on
May 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug provided on May 25, 2021.
You asked the Plan to pay for the self-administered drug. You say that you don't understand this denial or what
it is for. You say that you are on a very low income and concerned about the charges. The Plan denied your
request. The Plan says this must be submitted for processing under Part D.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 drug
provided on May 25, 2021.
Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on April 26, 2021 to April 28, 2021 by an out-of-network (OON) provider.
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 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 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 physician services provided on April 26, 2021 to April 28, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic analysis of cochlear implant (92604) provided on April 19, 2021.

You asked the Plan to pay for the diagnostic analysis of cochlear implant (92604). 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 must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services.

Though the diagnostic analysis of cochlear implant (92604) may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for the diagnostic analysis of cochlear implant (92604) provided on April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sensors for a continuous glucose monitor (K0553) provided on April 12, 2021.
You asked the Plan to pay for sensors for a continuous glucose monitor. You say that the requested items are a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met due to unsolicited phone contact by the supplier.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of sensors for a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for sensors for a continuous glucose monitor (K0553) provided on April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87428) provided to the enrollee on January 20, 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 the CLIA certification level is not met, per Medicare guidelines.

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, the CPT Code Manual definition of code 87428 is "Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B." 

We asked our coder 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 this should be paid for.. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation did not include modifier QW. Modifier QW is defined as a Clinical Laboratory Improvement Amendment (CLIA) waived test. CLIA requires all laboratory testing sites to have one of the following certificates to legally perform clinical laboratory testing: certificate of waiver; certificate of registration; certificate of accreditation; certificate for physician-performed microscopy procedures. 

We looked at this coder's review, the file, and Medicare rules. 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 laboratory services (87428) provided to the enrollee on January 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B prescription drug services rendered on April 27, 2021.
You asked the Plan to waive the coinsurance for these services. You say that the provider is in-network. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for chemotherapy and all other drugs covered under Medicare Part B.
Review of the file shows that you received Part B drug injection services on April 27, 2021. The Plan is not denying coverage for these services. The amount you are being asked to pay is your contractual coinsurance. You have been asked to pay a 20% coinsurance for these services.
These services fall within the chemotherapy and all other drugs covered under Medicare Part B 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 coinsurance for the Part B prescription drug services rendered on April 27, 2021