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

We decided that the Plan does not have to pay for a hands-free crutch and knee walker (E1399), purchased on July 30, 2021, and August 3, 2021.

You asked the Plan to pay for a hands free crutch and knee walker. You say that you needed these items. The Plan denied your request. The Plan says you purchased these items through a provider not enrolled in Medicare.

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 hands-free crutch and knee walker (E1399), purchased on July 30, 2021, and August 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nivolumab injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical indication for next line therapy with this drug.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injections. Our reviewer says that the requested injections is not medically reasonable or necessary. Our physician reviewer found Nivolumab Food and Drug Administration (FDA) approval is for the treatment of metastatic non-small cell lung cancer that has progressed on or after platinum-based chemotherapy. Patients with estimated glomerular filtration rate (EGFR) or anaplastic lymphoma kinase (ALK) genomic tumor aberrations should have disease progression (on approved EGFR-or-ALK-directed therapy) prior to receiving Nivolumab. The enrollee had a recent positron emission tomography (PET) scan that showed improvement and not has EGFR or ALK 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Nivolumab injections for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services for the application of a uniplane (20690) provided on May 31, 2021.
You asked the Plan to pay for the application of a uniplane (20690). You say that the surgical assistant provided services in the best interest of the patient and should not be denied payment. You say that the surgical assistant was chosen by the operating surgeon and payment should be made immediately. The Plan denied your request. The Plan says an assistant surgeon may not be paid for this procedure.
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) code 20690. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure.
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 the application of a uniplane (20690) have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services for the application of a uniplane (20690) provided on May 31, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the enrollee is in need to get to the SNF because it
will help with dialysis treatments while the enrollee has a trachea. You state there are no facilities in West
Virginia that would be helpful for the enrollee. The Plan denied your request. The Plan says the stay is not
medically necessary based on SNF criteria. The Plan states once the enrollee has completed their course of care
at the long-term acute care hospital (LTACH), intermittent therapy can safely be received at a different setting,
for example, home with home health or outpatient therapy in residential care, if the enrollee will participate.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found there are identifiable skilled nursing service
needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or
therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria
for an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 3, 2021.
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is a bundled service.
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 99212
is a column II code to column I code 64425. 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 office visit provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglass lenses (V2784) purchased on August 17, 2021.
You asked the Plan to pay for the lenses. You say that the Plan should cover these services in full. The Plan
denied your request. The Plan says they have paid the full $190 annual allowance for the eyewear, and you are
responsible for the remaining amount which exceeds this coverage limit.
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. The Plan covers these services up to $190 every year.
We looked at the file and the Plan's rules. Documentation shows that the total cost of the eyeglass lenses
purchased on August 17, 2021, was $247.50. The Plan paid $190 for these services, and you are being asked to
pay for the remaining $57.50 ($247.50 - $190 annual allowance = $57.50). Based on this information, you have
been asked to pay the correct amount based on your contract with the Plan. The annual allowance for
routine/prescription eyewear has been exhausted, and you are responsible for the remaining cost. Therefore, we
decided that the Plan does not have to pay any additional amount for the eyeglass lenses (V2784) purchased on
August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on September 15, 2021 by
an out-of-network (OON) provider.
You asked the Plan to pay for the debridement services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 debridement services provided on September
15, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) and an x-ray of the hand (73130) 
provided September 24, 2021.

You asked the Plan to pay for an office visit and an x-ray of the hand. You say that you would like this 
reviewed based on the contract with you and the Plan. The Plan denied your request. The Plan says services 
were rendered out-of-network 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 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. There was no evidence provided to show that you are a contracted provider with the Plan. 
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 an office visit (99203) and an x-ray of the hand (73130) provided September 
24, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene Panel provided on May 12, 2021.

You asked the Plan to pay for the Tempus Gene Panel. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that all the criteria listed in the Medicare Rules section of this letter must be 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 pay for the Tempus Gene Panel. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided records do not clearly document that the results of the testing did or would directly impact treatment or management of the enrollee as required in the Local Coverage Determination (LCD): Molecular Pathology Procedures (L35000). 

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 Tempus Gene Panel have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel provided on May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment rendered on July 22, 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 31 for a skilled nursing facility (SNF) setting; however, the file shows that the enrollee was not in a covered SNF stay and the POS code should be billed as 32. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment rendered on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitoring device (A9279), provided on May 11, 2021,
through September 10, 2021.

You asked the Plan to pay for the monitoring device. You say that the service is medically necessary. The Plan
denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that claims for A9279 (monitoring feature/device,
stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise
classified) are denied as statutorily non-covered (No Medicare benefit).

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the monitoring device have not been met. Therefore, we decided that the Plan does not have to pay
for the monitoring device (A9279), provided on May 11, 2021, through September 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on August 16,
2021.

You asked the Plan to waive the copayment for the colonoscopy. You say that this service should be covered.
The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $100
copay for outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $100 copay for the colonoscopy. This service falls within the outpatient
diagnostic tests and therapeutic services and 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
copayment for the colonoscopy provided on August 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy (45380), provided on 
August 16, 2021
.
You asked the Plan to waive the copayment for the colonoscopy. You say that the service should be covered.
The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
surgical service copay for outpatient surgery, including services provided at hospital outpatient facilities and
ambulatory surgical centers.
 
You have been asked to pay a $325 surgical service copay for the colonoscopy. This service 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 the colonoscopy (45380), 
provided on August 16, 2021.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the venous catheter removal. We decided that the
Plan does not have to waive the copayment for the venous catheter removal.
You asked the Plan to waive the copayment for the venous catheter removal. You say that the catheter removal
was done during the visit, there was not any type of surgical procedure. You say that the doctor's office is
making this charge when they shouldn't. The Plan says that the copayment applied correctly.
We decided that the Plan has to reduce the copayment for the venous catheter removal.
The Plan says you must pay a $200 copayment for an ambulatory surgical center visit. The records do not
support that the provider is an ambulatory surgical center. The provider is a nephrology specialist office, which
would apply a specialist copayment. Therefore, we decided that the Plan has to reduce the copayment from a
$200 ambulatory surgical center copayment to the $40 specialist copayment.
We also decided that the Plan does not have to waive the copayment for the venous catheter removal.
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 per specialist visit. Therefore, we decided that the Plan does not have to waive the copayment for
the venous catheter removal.
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 an eye exam provided on July 12, 2021.

You asked the Plan to pay for an eye exam. The Plan denied your request. The Plan says this service was covered for you on September 15, 2020. This means a calendar year had not elapsed when you received services on July 12, 2021. This benefit is administered on a rolling calendar year since your last date of service.

Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services once every year. 

We looked at the file and the Plan's rules. The file shows that you have exhausted your routine vision benefit. Based on this information, we decided that the Plan's rules for coverage of an eye exam have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam provided on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on 
February 4, 2021.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.

We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the place of 
service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was 
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of 
service 81; however, the submitted medical documentation and/or claim form history indicates that the 
specimen was obtained in an office setting, place of service 11. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing coded 80307 and G0482 provided on February 4, 2021.
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 transfer to an LTACH is medically
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an
LTACH are not met. The enrollee is receiving medically necessary acute and/or critical care at the current
facility, and these services have not been denied. The enrollee does not have clinical conditions that cannot be
appropriately treated in the current hospital, and there are no issues for which an LTACH may offer a
therapeutic advantage.
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 record indicates that the enrollee is improving but still requires high flow
oxygen and acute care services. The enrollee is receiving acute care services currently, and these have not been
denied. The medical record does not indicate that the enrollee requires services that they are not currently
receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 23, 2021, by an OON
provider.
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 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 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 office visit provided on June 23, 2021, by an
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation services (procedure code 97014)
provided to the enrollee on March 9, 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 this code is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 97014 is "Application of a modality to 1 or more areas;
electrical stimulation (unattended)."
We find that CPT code 97014 is not supported in the medical record. Specifically, this code has a status
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for
Medicare purposes.
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 electrical stimulation services (procedure code
97014) provided to the enrollee on March 9, 2021.