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

We decided that the Plan has to pay for the intravenous infusion for therapy, prophylaxis, or diagnosis (96365),
the laboratory service (85025), and the ferric carboxymaltos injection (J1439) provided on June 22, 2021.
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.
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. Specifically, the Plan contract states that through the Point of Service (POS)
benefit option members may receive certain services from out-of-network providers. However, the Plan
contract does not state what services are covered under this benefit. Therefore, we decided that the Plan has to
pay for the intravenous infusion for therapy, prophylaxis, or diagnosis (96365), the laboratory service (85025),
and the ferric carboxymaltos injection (J1439) provided on June 22, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and scaling in presence 
of generalized moderate or severe gingival inflammation (D4346) provided on July 21, 2021 by a Medicare opt 
out provider.

You asked the Plan to pay for the periodic oral evaluation and scaling. You say that you have always been 
reimbursed in the past by the Plan going to this same facility. The Plan denied your request. The Plan says you 
received this service from a provider who chose not to receive Medicare funds.

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, the requested items or services are not 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120) and scaling in presence of generalized 
moderate or severe gingival inflammation (D4346) provided on July 21, 2021 by a Medicare opt out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 2, 2021 to April 22, 2021.  

You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was submitted with an invalid type of bill code for home health services.  

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was billed with type of bill code 324. This is not a valid type of bill code for home health services. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from April 2, 2021 to April 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that there is medical necessity, as the enrollee has failed more than twelve months of conservative approaches at this time. The Plan denied your request. The Plan says there are currently no clinical indications for this technology.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on June 28, 2021.

You asked the Plan to pay for the genetic testing. 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.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. 

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on June 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies (CPT code(s): A4253, A4256, A4258,
A4259) provided to the enrollee on February 17, 2021.
You asked the Plan to pay for the diabetic supplies. You say that the claim should be paid. 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. Providers must report services with the appropriate CPT code. Our records indicate that procedure A4253, A4256, A4258, and A4259, which has a status indicator of 'P' on the CMS Physician Relative Value File, is always bundled into payment for other services not specified and no separate payment is made per Medicare. 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 the diabetic supplies (CPT code(s): A4253, A4256, A4258, A4259) provided to the enrollee on February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Optimizer cardiac contractility modulation system.  

You asked the Plan to pre-approve the requested services. You say that the enrollee has exhausted or failed conservative and standard of care treatment. The Plan denied your request. The Plan says its safety and efficacy has not been established.  

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 requested services. Our physician reviewer found that while the clinical studies led to food and drug administration (FDA) approval in 2019, a cardiac contractility modulation (CCM) system remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, the requested services is not considered to be medically necessary for this 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Optimizer cardiac contractility modulation system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel testing provided on June 2, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this test is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that test code 81455 is unlikely to impact therapeutic decision-making in the clinical management of a patient and will be denied automatically as not medically necessary. We looked at the file and Medicare rules. This test is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis panel testing provided on June 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a transport chair (E1038) provided on June 17, 2021.
You asked the Plan to pay for a transport chair. You say that the item at issue is a medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been met because the supplier of the item 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 a transport chair (E1038) provided on June 17, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (procedure code 81455) provided to the enrollee on June 11, 2021.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee has a diagnosis of decreased white blood cell count, unspecified. Genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the enrollee and will be denied automatically as not medically necessary. The review has determined that the enrollee does not meet the criteria for this testing. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (procedure code 81455) provided to the enrollee on June 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a walking boot (L4361) provided on July 6, 2021.

You asked the Plan to waive the coinsurance for the walking boot. You say that the services should be covered as the provider informed you that there would be no charge from the plan. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable medical equipment (DME) and related supplies.

You have been asked to pay a 20% coinsurance for the walking boot (the allowed amount is $207.10 x 20% = $41.42). Walking boots fall within the Durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the walking boot (L4361) provided on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220), bitewing x-rays (D0274), and 
patient screening (D0190) provided on April 24, 2018.

You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says the claim was received outside of the 12-month timeframe.

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 dental services was not filed until April 17, 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 periapical x-ray (D0220), bitewing x-rays (D0274), and patient screening 
(D0190) provided on April 24, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection provided on April 7, 2021.

You asked the Plan to waive the copayment for an epidural injection. You say that the injection did nothing. 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 $200 copayment for outpatient surgery, including services provided at ambulatory surgical centers. 

You received an epidural injection at an ambulatory surgical center on April 7, 2021. An epidural injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $200 copayment. 

You have been asked to pay a $200 copayment for an epidural injection. An epidural injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 epidural injection provided on April 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that this is needed for chronic pain. The Plan denied your request. The Plan says the clinical information submitted on appeal does not indicate imaging studies, physical therapy treatment, or neurosurgical evaluation.
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 stimulator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found more information is needed to qualify for a stimulator. There is no evidence of a neurosurgical evaluation. There is also no evidence of supportive documents to include imaging studies. 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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81455) provided June 4, 2021.

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 follows Medicare rules. Medicare rules say that genetic sequencing is covered when the patient has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer.

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 the genetic testing. Our reviewer says that the genetic testing was not medically necessary. Our physician reviewer found molecular profiling is now often performed on patients with myelodysplastic syndrome or hematological malignancies to evaluate for possible targeted therapy. However, this patient does not carry a diagnosis of myelodysplastic syndrome or a hematological malignancy. 

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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81455) provided June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids purchased on January 17, 2021.  You asked the Plan to pay for hearing aids. You say that these hearing aids are medically necessary, and you were hoping for partial payment. The Plan denied your request. The Plan says hearing aids are not covered by your plan under any condition.  The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services.   Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for hearing aids purchased on January 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) (CPT code 76705) provided to the enrollee on August 16, 2021.

You asked the Plan to pay for the ultrasound. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) (CPT code 76705) provided to the enrollee on August 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for primary procedure) (CPT code 22552).
You asked the Plan to pre-approve the service. You say that this surgery could change your life. The Plan denied your request. The Plan says the service is not 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 the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for cervical surgery not met. There is no correlation between imaging studies and exam. There is no documented instability. There is no documented recent trial of physical therapy (PT) for neck pain. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for primary procedure) (CPT code 22552).