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

We decided that the Plan does not have to pay for fundus photography with interpretation and report (CPT code 92250) provided on May 11, 2021.

You asked the Plan to pay for the service. You say that you would like for the Plan to pay for the denied code. The Plan denied your request. The Plan says you signed a consent form on May 11, 2021, acknowledging the refraction fee of $39 for digital imaging of the retina without the use of any eye drops was not covered and would be an out-of-pocket expense.

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. 

We looked at the file and the Plan's rules. The Medicare rules say that eye examinations for the purpose of prescribing, fitting or changing eyeglasses are not covered. Fundus photography with interpretation and report is not listed as a covered service under the supplemental vision care benefit. You signed a consent form acknowledging the service was not covered and you would pay the $39 out of pocket expense. Therefore, we decided that the Plan does not have to pay for fundus photography with interpretation and report (CPT code 92250) provided on May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, additional level
(22515).

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that there is no indication in the clinical notes or imaging reports that
there is evidence of a second compression fracture.

The Plan must follow Medicare rules. Medicare rules say that PVA is covered if LCD criteria are met.

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. There is no
documentation of a second spine fracture. Our physician reviewer found that your condition does not meet
Medicare criteria for 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 percutaneous vertebral augmentation, additional level (22515).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided December 16, 2020.

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that testing would be covered ONLY for the number
of genes or test that are reasonable and necessary to obtain necessary information for therapeutic decision
making.

We looked at the file and Medicare rules. Only literature and documentation from the genetic testing provider
were submitted for review. No clinical documentation was provided to show how these tests aided in
therapeutic decision making. 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 genetic testing
(81479) provided December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on April 20, 2021.
You asked the Plan to waive the copayment for an office visit. You say that this was your annual wellness exam and you should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $10 copayment for primary care provider visits. You had an office visit on April 20, 2021. Annual wellness exams are only covered once a year. The record shows that your previous annual wellness exam was less than a year ago at the time services were received. Therefore, you are responsible to pay the $10 copayment.
You have been asked to pay a $10 copayment for an office visit. An 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 an office visit provided on April 20, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cell enumeration using immunologic selection and identification in fluid specimen services coded 86153 provided on April 29, 2021.

You asked the Plan to pay for the cell enumeration using immunologic selection and identification in fluid specimen 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 a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that circulating tumor cells assay services are not covered. We looked at the file and Medicare rules. The services rendered are not a covered benefit. Based on this information, we decided that Medicare rules for coverage of the cell enumeration using immunologic selection and identification in fluid specimen services have not been met.

Therefore, we decided that the Plan does not have to pay for the cell enumeration using immunologic selection and identification in fluid specimen services coded 86153 provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient specialist office visits provided January 15, 2021 to February 1, 2021.
You asked the Plan to pay for the office visits. You say that in the beginning of January 2021 you fell ill with COVID-19 and the Plan repeatedly denied you coverage. With the Plan refusing coverage, you had no choice to go to this provider for treatment. The Plan denied your request. The Plan says If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. For date of service 02/01/2021 you were not enrolled.
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 the outpatient specialist office visits provided January 15, 2021 to February 1, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a ligation or banding of angioaccess arteriovenous fistula (37607) and an insertion of a needle or catheter (36902) provided with the aid of a surgical assistant on April 16, 2021.

You asked the Plan to pay for a ligation or banding of angioaccess arteriovenous fistula and an insertion of a needle or catheter. You say that the surgical assistant was chosen by the operating surgeon completely at the surgeon's discretion and the surgical assistant ethically could not deny services to the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 37607 and 36902. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for a ligation or banding of angioaccess arteriovenous fistula and an insertion of a needle or catheter have not been met. Therefore, we decided that the Plan does not have to pay for a ligation or banding of angioaccess arteriovenous fistula (37607) and an insertion of a needle or catheter (36902) provided with the aid of a surgical assistant on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis
vaccine provided on June 9, 2021.
You asked the Plan to pay for Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715). You
say that a pediatrician recommended the vaccine in order to hold your new grandson, so you immediately went
for the injection. The Plan denied your request. The Plan says this vaccine is not covered under your Medicare
Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, diphtheria
toxoids and acellular pertussis vaccine (Tdap) (90715). The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, diphtheria
toxoids and acellular pertussis vaccine (Tdap) (90715). Therefore, we decided that the Plan does not have to
pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine provided on June 9, 2021.
Benefits for Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) 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: 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 LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.

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 the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.

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 a transfer device (E0750).
You asked the Plan to pre-approve a transfer device. You say that because of severe injuries the enrollee needs a sliding board to transfer out of bed. The Plan denied your request. The Plan says this item is considered an item of comfort or convenience.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a transfer device is being requested for use in a SNF or a hospital. Therefore, we decided that the Plan does not have to pre-approve a transfer device (E0750).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for progressive lenses (V2781), polycarbonate lenses (V2784) and anti-reflective coating (V2750) provided on May 11, 2021.
You asked the Plan to hold you harmless for progressive lenses, polycarbonate lenses and anti-reflective coating. You say that you had cataract surgery on March 18, 2021 and glasses are covered. You also say that you confirmed with the Plan that after cataract surgery, you pay 20% of the charges; therefore, you would like this claim reconsidered. The Plan denied your request. The Plan says that these services are not a covered benefit.
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 progressive lenses, polycarbonate lenses and anti-reflective coating by a contract provider. The file does not show that the Plan provided notice that progressive lenses, polycarbonate lenses and anti-reflective coating would not be covered. Under Medicare rules, this means progressive lenses, polycarbonate lenses and anti-reflective coating is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for progressive lenses (V2781), polycarbonate lenses (V2784) and anti-reflective coating (V2750) provided on May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
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 treatment 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 procedure is considered an experimental/investigational procedure.
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, 22870).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (A0100, S0215) provided from September 1,
2020, to February 24, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not
payable.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee
Schedule indicates that the code in question is not valid for Medicare purposes.

We looked at the file and Medicare rules. Codes A0100 and S0215 are assigned a status indicator of "I" under
the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses
another code for reporting of, and payment for, these services. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for the services (A0100, S0215) provided from September 1, 2020, to February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) provided on February 23, 2021.

You asked the Plan to pay for the dental service. You say that the service was medically necessary. The Plan denied your request. The Plan says core build up is only covered in conjunction with a crown. The Plan says that there was no crown performed in conjunction with this service and therefore it is not covered. The Plan also says that core build up is not meant to be used as a filling restoration.

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 and core build up is listed as covered, it must be performed in conjunction with a crown to be eligible for coverage. The file does not show that a crown was performed. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on June 8, 2021.

You asked the Plan to pay for periodontal maintenance. You say that the service should be covered. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 6 months.

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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal maintenance have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on March 4, 2021.

Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on June 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically
necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current
level of care.
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 the documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
required medical services identified that are available at the LTACH, that are not available at the current health
care setting being offered by the health plan.
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 LTACH services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on November 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until March 30, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on November 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor and Dexcom sensors
(A9276).

You asked the Plan to pre-approve the continuous glucose monitor with sensors. You say that the CGM is
necessary. The Plan denied your request. The Plan says the documentation provided contains insufficient
evidence that the service is necessary.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.

We looked at the file and Medicare rules. The documentation does not indicate that the enrollee has had an in-person
visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment
plan. Based on this information, we decided that Medicare rules for coverage of the continuous glucose
monitor with sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve
continuous glucose monitor and Dexcom sensors (A9276).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (99439) and non-complex chronic care management (99490).

You asked the Plan to pre-approve chronic care management services. You say that you believe this should be approved as the enrollee has diagnosis for chronic conditions, making her eligible for chronic care management services. The Plan denied your request. The Plan says the request for chronic care management services are 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 pre-approve chronic care management services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not support eligibility and performance of the requested chronic care management services and are 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 chronic care management services have not been met. Therefore, we decided that the Plan does not have to pre-approve chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (99439) and non-complex chronic care management (99490).