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

We decided that the Plan has to pay for preventive medicine counseling provided on June 28, 2021.
You asked the Plan to pay for preventive medicine counseling (99402). You say that you were recommended to
see this provider and unaware the cost was not covered. The Plan denied your request. The Plan says that the
service is routine preventative counseling and not covered by Medicare.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for preventive medicine counseling (99402) by a contract provider. The file does not show
that the Plan provided notice that preventive medicine counseling (99402) would not be covered. Under
Medicare rules, this means preventive medicine counseling (99402) is considered approved by the Plan.
Therefore, we decided that the Plan has to pay for preventive medicine counseling provided on June 28, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3000).
You asked the Plan to pay for foot orthotics. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a ranibizumab eye injection (J2778) provided on June 17, 2021.
You asked the Plan to waive the coinsurance for an eye injection. You say that you received an injection of which was medically necessary but was not informed of the additional cost of $625. This was a referral due to scheduling issues. I am required to get these injections in both eyes 12 times a year. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.
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 out-of-network Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for an eye injection. The allowed amount of the claim is $3,122.60, resulting in a coinsurance obligation of $624.52. The EOC confirms that 20% is the required coinsurance for this service. An eye injection falls within the Medicare Part B prescription drugs 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 a ranibizumab eye injection (J2778) provided on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on May 26, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that it is illogical that the Plan will cover the work that was done, but not cover the exam that was provided to see how to treat the problem. The Plan denied your request. The Plan says this service exceeds the frequency limitation in 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on January 18, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (77002) provided on January 18, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 77002 has a bundled relationship with code 36561 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 services (77002) provided on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020) and spherocylinder single lenses (V2103) provided on April 5, 2021.
You asked the Plan to pay for eyeglass frames and single lenses. You say that when you asked the provider about your benefit eligibility, you were told you had $150 of covered benefits. You also say you have not made an optical purchase for over two years and you are unsure why you were denied coverage. The Plan denied your request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance.
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 contract says that you receive a $150 allowance to use towards the purchase of eyewear. If the eyewear you purchase is more than $150, you pay the difference. We looked at the file and the Plan's rules. The records show you exhausted your $150 maximum allowed benefit on April 5, 2021. The total cost of your eyewear was $359. You received the Plan's maximum allowed benefit of $150, which leaves a balance of $209 ($359 - $150 = $209). You are responsible for the remaining balance. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames and single lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020) and spherocylinder single lenses (V2103) provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 19, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because the specimen was obtained in the member's home and sent via mail. The Plan denied your request.
The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, this claim was billed with a laboratory POS code but the records indicate that this specimen was not collected in the laboratory. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 19, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on February 22, 2021.
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were rendered to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, no medical documentation was submitted.
We cannot determine whether Medicare coverage criteria are met in this case. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on February 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane (J9264).
You asked the Plan to pre-approve Abraxane. You say that this request is medically necessary. The Plan denied your request. The Plan says this drug is covered by Original Medicare as it is being provided in a clinical trial.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve Abraxane as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Abraxane (J9264).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician service provided on April 21, 2021 by an out-of-network provider.
You asked the Plan to pay for domiciliary or rest home visit (99336). You say that it is the facility's responsibility to get authorizations for their patients. The Plan denied your request. The Plan says the provider failed to obtain the required 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 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 these services. Therefore, we decided that the Plan does not have to pay for the physician service provided on April 21, 2021 by an out-of-network provider.
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 you would like the LTACH admission covered. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to an LTACH.

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 review has determined that there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital.

The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ten-month rental of a continuous positive airway pressure (CPAP) device (E0601) and heated humidifier (E0562).
You asked the Plan to pre-approve the seven-month rental of a CPAP device and heated humidifier. You say that the item is medically necessary. The Plan denied your request. The Plan says the Local Coverage Determination criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that continued coverage of a positive airway pressure (PAP) device (E0470 or E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document that the beneficiary is benefiting from PAP therapy. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the seven month rental of a CPAP device and heated humidifier have not been met. Therefore, we decided that the Plan does not have to pre-approve the ten-month rental of a continuous positive airway pressure (CPAP) device (E0601) and heated humidifier (E0562).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a thoracic computed tomography (CT) scan.

You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan. Our reviewer says that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has a lung mass suspicious for malignancy. The records indicate that the physician is planning to perform an electromagnetic navigation bronchoscopy. The records do not indicate that tissue diagnosis cannot be made through standard means that do not require repetition of the thoracic CT scan. The records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 

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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a thoracic computed tomography (CT) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network physician services on March 26, 2021.

You asked the Plan to pay for out of network services. You say that these services should be covered by the
Plan. The Plan denied your request. The Plan says your primary care physician's office confirmed you did not
have a referral from their office, and you did not have prior authorization from the Plan.

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 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 out-of-network physician services provided on
March 26, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on April 14, 2021.
You asked the Plan to pay for the services provided. You say that medical records justify the billed code. The Plan denied your request. The Plan says the claim does not comply with the emergency room note for code 99285.
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 99285 is Emergency department visit for the evaluation and management of a patient. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. We find that CPT code 99285 is not supported in the medical record. The records show the enrollee presented to the emergency room with anorexia and weakness. She was in no acute distress. She was treated for dehydration and chronic problems. The records do not show that the enrollee's presenting problems posed an immediate significant threat to life or physiologic function.
Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on April 14, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 11, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that no authorization is needed for these lab services. The Plan denied your request. The Plan says prior authorization was not obtained as required.
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 lab 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 lab services provided on December 11, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing coded 80307 provided on February 10, 2021.
You asked the Plan to pay for the genetic testing. 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 supported by the documentation.
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 80307 is drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service.
We find that CPT code 80307 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing coded 80307 provided on February 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery for the
enrollee.
You asked the Plan to pre-approve these services. You say that the patient is an excellent candidate for this
minimally invasive procedure. The Plan denied your request. The Plan says that experimental and
investigational procedures are not covered by Medicare.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device
is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer
found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Vertiflex superion device placement surgery for the enrollee.