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

 We decided that the Plan does not have to pre-approve radiofrequency ablation.  You asked the Plan to pre-approve radiofrequency ablation. You say that the requested radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested radiofrequency ablation.  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 radiofrequency ablation. Our reviewer says that the enrollee does not meet criteria for the requested radiofrequency ablation. Our physician reviewer found the enrollee has chronic low back pain. She has tried conservative therapy including Non-steroidal anti-inflammatory drugs (NSAIDs), Opiates, Muscle relaxants and physical therapy. She has had 5 radiofrequency ablation (RFA) sessions starting in 2018. Her last RFA session was on September 28, 2021 and the request is to repeat the RFA. Her pain relief did not last 6 months at greater than 50%. The request exceeds the utilization criteria and did not achieve greater than 50% pain relief for 6 months.  Therefore, the request is deemed not medically reasonable or 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on July 8, 2021.

You asked the Plan to pay for CT scan 70450. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 70450 has a procedure-to-procedure (PTP) edit of 1 with code 70496 so cannot be separately paid without an appropriate modifier.

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 CT scan 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 a computed tomography (CT) scan (70450) provided on July 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).

You asked the Plan to pre-approve Durolane. You say that the requested drug is medically necessary for the enrollee's diagnosis. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Orthovisc and Monovisc.

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 Durolane. Our reviewer says that the request for Durolane is not medically necessary. Our physician reviewer found he provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternatives, Orthovisc and Monovisc. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternatives. Therefore, the reviewer found that the step therapy criteria have not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Specifically, the file shows that the enrollee has not tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0012M) provided March 10, 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 this service is non-covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare has reaffirmed non-coverage for CPT
code 0012M.
We looked at the file and Medicare rules. The code billed is not covered under 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 (0012M) provided March 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's level of function is too low to be considered for acute inpatient rehabilitation level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical management of an upper extremity fracture. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 25, 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 denied codes remain not supported.

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 the various denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a skilled nursing facility. (POS 31), while the records reflect of place of service of a doctor's office (POS 11). 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 provided to the enrollee on January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lipid panel: This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478) (CPT code 80061-AY) provided to the enrollee on June 9, 2021.
You asked the Plan to pay for the service. You say that the services were medically necessary. The Plan denied your request. The Plan says this was denied because it was not reported with an approved diagnosis.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, the service, 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 lipid panel: This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478) (CPT code 80061-AY) provided to the enrollee on June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (74181) provided August 10, 2021.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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 74181 has a bundled relationship with code 74183. 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 radiology services (74181) provided August 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 20, 2021.

You asked the Plan to waive the copayment for an ultrasound. You say that you feel that you should only owe a $30 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 $110 copayment for ultrasounds. 

You have been asked to pay a $110 copayment for an ultrasound. An ultrasound 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 an ultrasound provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92004) and the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; of the retina (92134) rendered by the out-of-network (OON) provider on June 15, 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.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92004) and the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; of the retina (92134) rendered by the out-of-network (OON) provider on June 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 2, 2021, to July 12, 2021, and July 17, 2021, to July 31, 2021.

You asked the Plan to pay for the SNF care provided from July 2, 2021, to July 12, 2021, and July 17, 2021, to July 31, 2021. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive any skilled services during the dates of service in this case.

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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care provided from July 2, 2021, to July 12, 2021, and July 17, 2021, to July 31, 2021, have not been met. Specifically, the file does not show that the enrollee received daily skilled care during the dates of service in question. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 2, 2021, to July 12, 2021, and July 17, 2021, to July 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from October 22, 2019, to October 24, 2019.   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 DRG for the inpatient admission was reassigned.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with . 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 services at issue in this case were not supported by the medical records. Our physician reviewer found at the time of discharge he did not require supplemental oxygen. The review has determined that the appropriate DRG and diagnosis codes were not used in this case.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from October 22, 2019, to October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667 and E0668).  You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you are asking for approval of the Flexitouch to reduce risk of further skin breakdown and infection. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667 and E0668).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an occlusal guard (D9944) provided by a participating provider.  You asked the Plan to pre-approve an occlusal guard. You say that you would like approval for this night guard. The Plan denied your request. The Plan says an occlusal guard is not a covered benefit.  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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard (D9944) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).
You asked the Plan to pre-approve a complete upper denture. You say that you need a new set of dentures badly. You say that you cannot chew well. You also say that you are on dialysis and need to take your medication with food. The Plan denied your request. The Plan says 1 complete upper denture is covered every 60 months. The Plan also says that the frequency limit has been reached.
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 a complete upper denture have not been met. Specifically, the file shows that the frequency limit
has been reached. The record shows that the Plan paid for a complete upper denture that you received on July 10, 2017. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the fixed partial denture sectioning (D9120).
You asked the Plan to pre-approve the fixed partial denture sectioning (D9120). The Plan denied your request.
The Plan says the service is not a covered benefit.
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
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
fixed partial denture sectioning (D9120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (84153, 84439, 80061, 84443, 85025) provided December 30, 2020.
You asked the Plan to pay for the lab services. You say that the lab testing was medically necessary. The Plan denied your request. The Plan says these services were for screening purposes and are non-covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The lab services at issue were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (84153, 84439, 80061, 84443, 85025) provided December 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on August 12, 2021.  You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you contacted the paramedics because you have a history of fainting spells, but were sweating profusely, and felt like you might be dying. You also say that after the paramedics checked you out, you felt much better and declined being taken to the hospital. The Plan denied your request. The Plan says this expense is not covered by your plan. The Plan also says that Medicare ambulance benefit is a transport benefit, and if no transport of a Medicare beneficiary occurs, there is no Medicare-covered service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on August 12, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitoring (CGM) system.

You asked the Plan to pre-approve the CGM system. You say that the medical records provided support the need for the requested CGM. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM system have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitoring (CGM) system.