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

We decided that the Plan does not have to pre-approve a portable ventilator.

You asked the Plan to pre-approve home ventilator, any type, used with non-invasive interface, (e.g., mask,
chest shell) (E0466). You say that you need a ventilator. The Plan denied your request. The Plan says the
requested device would be used in a bilevel positive airway pressure (BiPAP) mode that could be provided
with a BiPAP device with average volume-assured pressure support (AVAPS) added.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve home ventilator, any type, used with
non-invasive interface, (e.g., mask, chest shell) (E0466). Our reviewer says that a home ventilator is not
medically necessary. Our physician reviewer found this patient has a diagnosis of chronic obstructive
pulmonary disease and congestive heart failure, with recent hospitalization for acute on chronic hypoxic and
hypercapnic respiratory failure. The patient improved on bilevel positive airway pressure (BiPAP) in the
hospital. BiPAP has not been tried at home according to the medical record. Medicare does not cover a home
ventilator when used as BiPAP, and the average volume-assured pressure support (AVAPS) mode of support
can be provided via BiPAP. The denial is upheld.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home ventilator, any type, used with non-invasive interface, (e.g., mask, chest
shell) (E0466) have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable
ventilator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (85390) provided February 25, 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 services were for screening purposes and are non-covered.

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 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 lab services (85390)
provided February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that your medication results having frequent urination that is out of your control. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue expander placement in breast reconstruction (19357), breast reconstruction (19361), the insertion of a breast implant on the same day of a mastectomy (19340), the excision of a benign lesion including margins, except skin tag (11406), and the implantation of a biologic implant (15777) rendered by the out-of-network (OON) provider on November 11, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 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 tissue expander placement in breast reconstruction (19357), breast reconstruction (19361), the insertion of a breast implant on the same day of a mastectomy (19340), the excision of a benign lesion including margins, except skin tag (11406), and the implantation of a biologic implant (15777) rendered by the out-of-network (OON) provider on November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87541, 87581, 87640, and 87798) provided on November 30, 2020.

You asked the Plan to pay for the laboratory services. 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 as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an nursing facility setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87541, 87581, 87640, and 87798) provided on November 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (75726, 75774) provided April 2, 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 these services were part of another procedure and 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. 

We find that CPT codes 75726 & 75774 are not supported in the medical record. Specifically, the primary procedure (37243) is inclusive of the imaging procedures performed. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (75726, 75774) provided April 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.

You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary. The Plan denied
your request. The Plan says step therapy requirements have not been met.

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 Synvisc-One. Our reviewer says that the requirements for coverage of Synvisc-One have not been met. Our physician reviewer found the Plan requires a trial of Durolane, Euflexxa, Supartz, or Gelsyn-3 before they will approve the requested drug. The records do not show that you have tried any of these drugs, that they would likely be less effective, or that they would likely have adverse effects. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound (76700) provided on July 28, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an ultrasound in a freestanding radiological facility on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Outpatient diagnostic tests provided in a freestanding radiological facility. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an ultrasound in a freestanding radiological facility on July 28, 2021. You have been asked to pay a $40 copayment for the ultrasound. The ultrasound falls within the Outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound (76700) provided on July 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography (77067) screening digital
tomosynthesis for mammography (77063) provided on January 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the diagnostic service. You say that this is the same mammogram location you
used in 2019, 2020 and now 2021 at the recommendation of your primary care physician. The Plan denied your
request. The Plan says enrollee's must receive their medical services from an in-network provider with the
exception being urgent or emergent services. Non-emergent services with non-contracted providers require
prior authorization before services being rendered.

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 screening mammography (77067) screening
digital tomosynthesis for mammography (77063) provided on January 22, 2021 by an out-of-network (OON)
provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from October 16, 2020, through October 18, 2020.

You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on October 15, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided from October 16, 2020, through October 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (21299) provided on September 18, 2020.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were non-emergent. 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 surgical services (21299) provided on September 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right leg sclerotherapy.

You asked the Plan to pre-approve right leg sclerotherapy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that sclerotherapy 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 right leg sclerotherapy. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found there is a lack of consistency in the documentation of symptoms in that one document notes right leg swelling and discoloration and only a right sided duplex was obtained. There is another document based on the same visit that appears more formatted and notes bilateral leg pain. There has been no follow-up visit describing the treatment plan for the superficial venous thrombosis including the proximal right greater saphenous vein thrombosis nor an effort to see if the patient's symptoms improved after the acute thrombotic event has resolved. There is no assessment reviewing the symptomatic data and the duplex data with associated cohesive plan of treatment. Therefore, the enrollee does 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 right leg sclerotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve right leg sclerotherapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the temporary crown (D2970 x 3), gingivectomy (D4211 x 2), retainer crowns (D6740 x 2), pontic (D6245), extraction (D7210), core build up (D2950), limited oral evaluation (D0140), periapical x-ray (D0220), and filling (D2335) provided from December 9, 2020, to February 08, 2021.

You asked the Plan to pay for the dental services. You say that you were given misinformation by a plan representative. You say that you were advised you had in network dental coverage. You say that you made an appointment and had the work done. You also say that you now owe thousands of dollars. The Plan denied your request. The Plan says routine dental services are not covered by Medicare or the Plan.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for 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 pay for the temporary crown (D2970 x 3), gingivectomy (D4211 x 2), retainer crowns (D6740 x 2), pontic (D6245), extraction (D7210), core build up (D2950), limited oral evaluation (D0140), periapical x-ray (D0220), and filling (D2335) provided from December 9, 2020, to February 08, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray of the shoulder you had on July 21, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that you have never had to pay a copayment for x-rays before and you believe it should be included in the office visit copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for x-rays and ultrasounds. You have been asked to pay a $40 copayment for the x-ray. Plans are permitted to charge separate cost sharing for diagnostic imaging that occurs during an office visit. 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 x-ray of the shoulder you had on July 21, 2021.
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 the requested procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered 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 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 remains experimental for low back pain. More research is needed to show safety and efficacy. 

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional OT visits.

You asked the Plan to pre-approve additional OT visits. You say that additional OT visits are medically necessary. The Plan denied your request. The Plan says additional OT visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 additional OT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on review of the available records, the enrollee does not meet Medicare coverage criteria for additional occupational therapy visits when he showed no progress attending the few therapy visits. The enrollee is with old Anoxic encephalopathy with prior traumatic brain injury and with functional dependence will not change with cognitive deficits. So far, the enrollee did not demonstrate any progress to justify additional therapy visits. The documentation does not support coverage for additional occupational therapy visits. The requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. The specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional OT visits.