Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 81206, 81235, 81292, 81301, and 81321 provided on May 3, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT codes 81206, 81235, 81292, 81301, and 81321 are not supported in the medical record. Specifically, if a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. Review of the file does not support that only one code was billed for the panel provided. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81206, 81235, 81292, 81301, and 81321 provided on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341) for the upper left quadrant and gingival irrigation - per quadrant (D4921) for all four quadrants provided August 24, 2021.   You asked the Plan to pay for the periodontal scaling and root planing and gingival irrigation. You say that you feel your provider should have correctly checked your benefits and informed you of the full cost prior to rendering the services. The Plan denied your request. The Plan says you have exceeded the frequency limit for the periodontal scaling and root planing for the upper left quadrant and the gingival irrigation is not a covered 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 the periodontal scaling and root planing once per quadrant every three years.   We looked at the file and Medicare rules. The Plan provided documentation showing that periodontal scaling and root planing was previously covered for the upper left quadrant on February 13, 2019. Based on this information, we decided that the Plan's frequency limit for coverage of the periodontal scaling and root planing has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, gingival irrigation is not among those covered services. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341) for the upper left quadrant and gingival irrigation - per quadrant (D4921) for all four quadrants provided August 24, 2021.    Your complaint about the network provider potentially providing incomplete or inaccurate information about cost prior to the services being rendered 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: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve adjustable volume socket (CPT code L5999).  You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. The Plan says that experimental items and items that are not shown to be safe and effective cannot be covered; therefore, that requested adjustable volume socket cannot be covered and a standard socket was already approved.  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 item. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you would fail a standard socket as your stump is large. An adjustable socket is supported based on the provided physician statement. Therefore, the adjustable volume socket will be considered medically necessary and reasonable.  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 item have not been met. Therefore, we decided that the Plan has to pre-approve adjustable volume socket (CPT code L5999).   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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing rendered on June 8, 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 the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cytopathology services provided on July 14, 2021.  You asked the Plan to pay for the cytopathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered 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 cytopathology services 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 the cytopathology services provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve steroid injections (62321).  You asked the Plan to pre-approve the steroid injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that Epidural Steroid Injections are covered for a pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or medical documentation of failure to respond to four (4) weeks of noninvasive conservative care.   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 steroid injections. Our reviewer says that the requested injections are not medically necessary. Our physician reviewer found there is no evidence of radiculopathy to upper extremities or neurogenic claudication. Cervical epidural steroid injections are not indicated for the presence of axial neck pain. There is also no mention of a pain scale or baseline pain measurement in the provided records. There is no record of non-invasive conservative 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 the steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve steroid injections (62321).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Cialis.  You asked the Plan to pre-approve Cialis. You say that the medication is working well and should be continued. The Plan denied your request. The Plan says Cialis to be administered at home is not covered under the Part B benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 pre-approve Cialis.     Benefits for Cialis 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the MRI scan of leg joint.  You asked the Plan to pre-approve the MRI. You say that you are requesting the approval of the MRI that can direct the surgeon to make the exact precise cuts on the bone for your upcoming knee replacement instead of relying on an x-ray. The Plan denied your request. The Plan says the notes do not show that these x- ray findings are present. The Plan states the notes also do not show that you have hardware in your knee and based on the information they have, this MRI is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our physician reviewer found the record indicates that you have osteoarthritis of the knee and is scheduled for knee arthroplasty. The provided record does not support that the requested service is medically necessary and reasonable for the diagnosis and treatment for your clinical condition at this time. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the MRI scan of leg joint.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on September 22, 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 appropriate modifier was not billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT).  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that HBOT is covered for specific indications only.  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 enrollee does not have a condition for which HBOT is covered. Our physician reviewer found the enrollee has chronic peripheral arterial disease and not an acute case. There are no other indications noted in the submitted records to support this request, such as a non-healing wound. The criteria for coverage are not met and the HBOT is not medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on March 15, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the original appointment was scheduled in 2020 when the coronavirus waiver was in effect, and you should not be responsible for the copayment since it was rescheduled. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  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 $30 copayment for each specialist visit.   You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a specialist office visit provided on March 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services performed by a qualified physical therapist (G0151), direct skilled nursing services of a registered nurse (RN) (G0299), and home health care provided in patient's home/residence (Q5001) provided from June 2, 2021, to July 1, 2021.  You asked the Plan to pay for the services performed by a qualified physical therapist, direct skilled nursing services of a RN, and home health care. You say that other claims have processed and paid despite being received in 5 calendar days or not. The Plan denied your request. The Plan says the initial Request for Anticipated Payments (RAP) claim was not received within 5 calendar days from the start of care. The Plan also says that the RAP claim was submitted on July 26, 2021.  The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day periods and within 5 calendar days after the "from date" for each subsequent 30-day period of care, which is set at 0 percent at the beginning of every 30-day period.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services performed by a qualified physical therapist, direct skilled nursing services of a RN, and home health care have not been met. Specifically, the record indicates the RAP was not submitted within 5 days of the from the start of care date, June 2, 2021.  Therefore, we decided that the Plan does not have to pay for the services performed by a qualified physical therapist (G0151), direct skilled nursing services of a registered nurse (RN) (G0299), and home health care provided in patient's home/residence (Q5001) provided from June 2, 2021, to July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.  You asked the Plan to pre-approve the requested services. You say that you are having trouble breathing. The Plan denied your request. The Plan says you do not meet the criteria.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file, and Medicare rules. The records show that prior to your recent visit, you were last seen in 2017. There is no documentation of prior failure with the device. There is no documentation of a recent repeat sleep study. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90832) provided on August 26, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for psychotherapy services have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  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, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Fluid Flow injections rendered on September 20, 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 the services were not medically necessary.  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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee had left knee pain and arthralgia. Fluid Flow injections are not shown to be safe and effective in long-term studies and there is a lack of evidence to support that joint injection of human amniotic fluid is not considered experimental/investigational in nature. The services were therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the Fluid Flow injections rendered on September 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90791) provided on August 12, 2021.  You asked the Plan to pay for psychotherapy services. You say that the provider at issue was your only option and that a representative of the Plan recommended that you utilize the provider's services. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue is not enrolled in the Medicare program.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90791) provided on August 12, 2021.   Your complaint about receiving erroneous or incomplete information about your benefits from a representative of the Plan 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: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer.  You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says the enrollee has not tried and failed Ferrlecit, Infed, or Venofer.   Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Injectafer. Our physician reviewer found that you have iron deficiency anemia. The Plan requires a trial of Ferrlecit, Infed, or Venofer before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs would likely be less effective or likely have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided from September 3, 2021, to September 8, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you would like to appeal this service. The Plan denied your request. The Plan says Medicare does not pay for this service.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 drugs provided from September 3, 2021, to September 8, 2021.  Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.