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

We decided that the Plan does not have to pre-approve continued 14-day rental of a negative pressure wound
therapy pump.
You asked the Plan to pre-approve continued 14-day rental of a negative pressure wound therapy pump. You
say that you have shown huge improvement. The Plan denied your request. The Plan says the requested
services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that continued rental of a negative pressure wound
therapy pump is only covered for certain indications.
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 continued 14-day rental of a negative
pressure wound therapy pump. Our reviewer says that the documentation does not support that the requested
services are medically reasonable or necessary.
Our physician reviewer found on March 29, 2021 the wound measured 3.4 cm L x 2.8 cm W x 3 D cm. On May 10, 2021, wound measured 3.4 cm L x 3.4 cm W x 3.2 cm D. On June 17, 2021, the wound measured 3.2 cm L x 2.6 cm W x 2.5 cm D. On July 29, 2021, the wound measured 3.5 cm L x 2.5 cm W x 2.5 cm D. Per Medicare criteria, ongoing coverage of wound vac is denied as not reasonable and necessary when there has been no measurable degree of wound healing over the prior month. Additionally, Medicare criteria states that ongoing coverage of wound vac stops after four months of therapy. In your case, the wound size has not shown significant improvement in size and it has been more than four months since initiation of wound vac treatment. Therefore, you do not meet criteria for the requested 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 continued 14-day rental of a negative pressure wound therapy pump have not been met. Therefore, we decided that the Plan does not have to pre-approve continued 14-day rental of a negative pressure wound therapy pump.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on February 15, 2021.
You asked the Plan to pay for the drug 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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation did not include progress notes that were needed to determine the clinical utility of the testing rendered. The Plan attempted on various occasions to received this required documentation. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain fused to high noble metal for tooth 30
(D2750) provided March 22, 2021.
You asked the Plan to pay for the crown. You say that the provider called and had all three crowns authorized.
The Plan denied your request. The Plan says the call record shows that the dentist only verified provider status
but did not specifically ask about any benefits. You have exceeded the frequency limit for this service.
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. The Plan covers two crowns
per calendar year.
We looked at the file and Medicare rules. The Plan provided documentation showing that 2 crowns were covered on the same date of service. Based on this information, we decided that the Plan's frequency limit for coverage of the crown has been exceeded. Therefore, we decided that the Plan does not have to pay for the crown - porcelain fused to high noble metal for tooth 30 (D2750) provided March 22, 2021.
Your complaint about the Plan potentially providing misinformation about benefits is not a valid appeal 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nutrition therapy provided on January 25, 2021.
You asked the Plan to pay for medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (97802). You say that the diagnosis codes are appropriate. The Plan denied your request. The Plan says the diagnosis codes do not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. The claim did not contain a diagnosis of renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for nutrition therapy provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy services (90837) provided on January 5, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has not provided any documentation or evidence pertaining to the provider not qualifying as a covered psychologist. We find that the Plan has not provided a valid reason for denial of payment for the psychotherapy services. Therefore, we decided that the Plan has to pay for the psychotherapy services (90837) provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the dermatology services provided on March 22, 2021.
You asked the Plan to waive the cost share for the services provided. You say that the annual skin screening is a preventive service. The Plan denied your request. The Plan says you are responsible for your share of the cost.
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 $300 deductible. The file shows you received dermatology services. Your Plan contract does not show a benefit for preventive dermatology services. The services fall within the physician services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible. This cost sharing is a contractual obligation that had not been met at the time the services provided was received on March 22, 2021. Therefore, we decided that the Plan does not have to waive the cost share for the dermatology services provided on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vascular mat therapy services provided on February 15, 2021, and March 12, 2021.
You asked the Plan to pay for the services provided. You say that the service has been helpful with his foot. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the vascular mat therapy services provided on February 15, 2021, and March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 endosteal implants (21249).
You asked the Plan to pre-approve the dental services. You say that the enrollee received an oral appliance for sleep apnea and TMJ (temporomandibular joint) disorder needs. You say that the enrollee has no teeth. You say that the enrollee needs 4 implants to keep a denture in place so that they can wear the oral appliance. You also say that this is medically necessary. The Plan denied your request. The Plan says implants are not listed as covered routine dental services. The Plan also says that implants are not a benefit that Medicare would cover.
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, endosteal implants are not among those covered under this benefit. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 4 endosteal implants (21249).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee needs to stay in the facility longer for services. You say that the enrollee has seen decreased cognitive and physical ability. You say that the enrollee has had multiple strokes and transient ischemic attacks, which have greatly reduced his ability to return to independent living. You say that there are no family members who are able to provide 24-hour care for the enrollee. The Plan denied your request. The Plan says the guidelines for coverage have not been met.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the enrollee requires skilled nursing services. The specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does require skilled therapy services, but they are not required on a daily basis. The enrollee does not require skilled services on an inpatient basis, only in a SNF setting. Services in the home with home health care, or in a long-term care facility on a part-time basis appear appropriate 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 test provided on March 29, 2021.
You asked the Plan to pay for the Guardant360 test. You say that the test is covered by Medicare so the claim should be paid. The Plan denied your request. The Plan says the enrollee meets the medical necessity criteria for the panel however the test was billed as a panel of codes.
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 the Guardant360 cannot be paid as billed with incorrect CPT codes. Medicare rules say the Guardan360 test is billed with CPT code 81479. Based on this information, we decided that Medicare rules for
coverage of the Guardant360 test have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 test provided on March 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested treatment is considered an experimental/investigational procedure because it has not demonstrated superior outcomes to the standard decompression procedure. Placement of an interspinous spacer would also not address your extruded disc. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided April 28, 2021.
You asked the Plan to waive the copayment for the emergency ambulance services. You say that you thought the ambulance transport would be covered because it was related to coronavirus (COVID-19). The Plan denied your request. The Plan says this service is not covered under the Plan's COVID-19 copay waiver. 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 $250 copayment for Medicare-covered ambulance services.
You have been asked to pay a $250 copayment for the emergency ambulance services. This service falls within the Ambulance services benefit category. We reviewed the Plan's COVID-19 copay waiver and found that ambulance copayments are not included in the waiver. 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 ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on June 2, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the enrollee is entitled to receive surgical dressings as a covered benefit. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the wound care services provided on June 2, 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 angiography services coded 75710 and 75774 provided on March 3, 2021.
You asked the Plan to pay for the angiography services. 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 75710 for the angiography services has a bundled relationship with code 37227 and cannot be paid as billed. Also, in this case, we have confirmed that code 75774 for the angiography services has a bundled relationship with code 37227 and cannot be paid as billed. These codes 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 angiography services coded 75710 and 75774 provided on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the coinsurance for continuous glucose monitor (CGM) sensors you purchased on March 25, 2021.
You asked the Plan to waive the coinsurance for the CGM sensors. You say that you do not understand why you keep getting billed for these supplies. The Plan denied your request. The Plan says that you were charged this coinsurance correctly because the allowed amount per month for these supplies is over $500.
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 enrollees do not pay cost sharing for diabetes supplies, including supplies to monitor your blood glucose. The sensors you purchased are supplies used with a CGM to monitor your blood glucose, so they fall into the diabetic supply benefit category. According to your contract, items in this category do not have cost sharing associated with them. The Plan contends that the durable medical equipment cost sharing applies. While the Evidence of Coverage states that diabetic supplies are covered under the durable medical equipment benefit, that information is contrary to the language in the Diabetic Services and Supplies section of the Evidence of Coverage. Diabetic supplies cannot fall into both categories, so we find that the Plan's contract is not clear. A reasonable person would not be able to tell, based on the language of the Plan's document, under which benefit section diabetic supplies would be covered. Due to this lack of clarity, we can only conclude that the benefit section that is more beneficial to you would apply. The diabetic supply category, as noted above, clearly includes supplies used to monitor blood glucose. That includes CGM sensors. Based on the language of the contract, a reasonable person would conclude that there would be no cost sharing associated with these items. Therefore, we decided that the Plan has to waive the coinsurance for continuous glucose monitor (CGM) sensors you purchased on March 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services provided from January 28, 2021, through February 26, 2021.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the member was at baseline and did not require therapy in a skilled setting. There were also no skilled nursing needs.
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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, it is my opinion that the enrollee did not qualify for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical matter, could be provided at a lower level of care (ex. long term care). 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services provided from January 28, 2021, through February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on January 4, 2021 to January 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that there was sufficient evidence of medical necessity. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the wound care 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 OON services. Therefore, we decided that the Plan does not have to pay for the wound care services provided on January 4, 2021 to January 18, 2021 by an out-of-network (OON) provider.