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

We decided that the Plan does not have to pre-approve a knee orthosis.
You asked the Plan to pre-approve knee orthosis. You say that this is a medical need for you. The Plan denied your request. The Plan says this knee orthosis is not medically necessary.
The Plan follows Medicare rules. Medicare rules state that custom fabricated knee orthoses are not reasonable and necessary when the beneficiary is non-ambulatory.
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 knee orthosis. Our reviewer says that you do not meet the Medicare criteria for the requested knee orthosis. Our physician reviewer found you are not ambulatory due to your ankle fracture; therefore, this orthosis is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the alveoloplasty not in conjunction with extractions (D7320 x 3) provided on June 24, 2021, by the out of network provider.
You asked the Plan to pay for the dental services. You say that you received these services from a licensed oral surgeon. You say that you received an estimate showing a total discount of $1,605 for the services you received. You also say that the services should be covered due to the conflicting information you were given. The Plan denied your request. The Plan says dental service received out of network are not covered.
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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the alveoloplasty not in conjunction with extractions (D7320 x 3) provided on June 24, 2021, by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene Panel (81210, 81235, 81245, 81272, 81275, 81276, 81310, 81311 and 81315) provided on February 20, 2021.
You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says this claim has not been billed correctly.
The Plan must follow Medicare rules. Medicare rules say that CPT code 81455 should be billed when 51 or greater genes are ordered for molecular biomarkers.
We looked at 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. Specifically, the documentation indicates that the Tempus Gene Panel tests 648 genes. It is not appropriate to bill each gene individually in this instance. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel (81210, 81235, 81245, 81272, 81275, 81276, 81310, 81311 and 81315) provided on February 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic behavioral services (H2019) provided on July 6, 2021 to September 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the behavioral health services. You say that there has been no payment on this claim and you would like this to be reprocessed and paid. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 therapeutic behavioral services (H2019) provided on July 6, 2021 to September 9, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided October 6, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you needed this x-ray to evaluate a problem and were unaware that there was a frequency limit. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the complete series of intraoral x-rays once every 3-year period. We looked at the file and Medicare rules. A complete series of x-rays were previously covered by the Plan on December 5, 2019. Based on this information, we decided that the Plan's frequency limit for coverage of the complete series of intraoral x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided October 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.
You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation of joints other than the knee(s) are considered not reasonable and necessary and are not subject to coverage. We looked at the file and Medicare rules. The file indicates Synvisc-One is being requested for the hip. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the nursing facility care (99309) provided on September 14, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the claim form has missing or invalid revenue codes.

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. In this case, the revenue and type of bill codes are appropriate. The Plan has not provided documentation supporting its denial. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the nursing facility care (99309) provided on September 14, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a visual field examination (92083) rendered on October 28, 2021.

You asked the Plan to waive the copayment for a visual field examination. You say that you went to see a cataract specialist, but during that appointment all they did was the exact same field of view test that was done on the August 2, 2021, appointment. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for medical care or surgery services in a Specialty Physician's office.

You have been asked to pay a $30 copayment for a visual field examination. A visual field examination falls within the physician/practitioner services, including doctor's office visits benefit category. The record shows you were seen by the physician on October 28, 2021. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a visual field examination (92083) rendered on October 28, 2021.

Your complaint about the provider potentially only giving the exact same test as the previous visit is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99213) therapeutic ultrasound (97035) electrical stimulation (G0283) application of a modality, hot/cold packs (97010) provided October 8, 2020.

You asked the Plan to pay for the chiropractic service. You say that you want to appeal the decision of denial. You were covered at the time and the provider was late in submitting this claim. The Plan denied your request. The Plan says these services are not covered under the Plan benefits.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99213) therapeutic ultrasound (97035) electrical stimulation (G0283) application of a modality, hot/cold packs (97010) provided October 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 6, 2021, to October 7, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says the inpatient admission was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided documentation indicates that the enrollee had an uneventful recovery, had stable vital signs and their dressing was stable. The documentation also indicates that the enrollee was progressing with therapy. Based on the documentation provided, the reviewer found that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 6, 2021, to October 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actifuse allograft for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a standard allograft product.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that Actifuse allograft remains experimental for use in spinal surgery. More research is needed. 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 pre-approve Actifuse allograft for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on September 9, 2021.
You asked the Plan to pay for the eye refraction. You say that these services were medically necessary to treat the enrollee's dry eye, and this provider is contracted to provide care to patients in this facility. The Plan denied your request. The Plan says they have agreed to pay for the eye exam and lens; however, the criteria for coverage of an eye refraction are not met, and this service remains denied.
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 eye refractions when they are provided as part of a routine eye exam performed by a provider in the Plan's specified routine vision vendor network.
We looked at the file and the Plan's rules. The eye refraction in this case was provided with a medical (Medicare-covered) eye exam rather than a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on September 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdomen angiography rendered on September 16, 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 are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 75726 (abdomen angiography) and 37244 (vascular embolization). Code 75726 is a column II code with a modifier indicator of 1 when billed with column I code 37244. Code 75726 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the abdomen angiography rendered on September 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexcom G6 therapeutic continuous glucose monitor
(CGM) (K0554) and receiver (K0553).
You asked the Plan to pre-approve CGM. You say that the requested CGM is medically necessary. The Plan denied your request. The Plan says the criteria 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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 therapeutic continuous glucose monitor (CGM) (K0554) and receiver (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says the enrollee does not meet the criteria.
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 uses insulin with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested service have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 19, 2022 with chronic thigh pain and difficulty walking. He was diagnosed with acute cystitis without hematuria and leukocytosis. His current level of function as of February 24, 2022 requires modified assistance with bed mobility and sitting to standing. He needs maximal assistance of two to walk with a standing walker. He does not have complex wound care needs. He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the enrollee is on Coumadin and you can administer Euflexxa with a smaller needle and less bleeding risk. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Orthovisc, Synvisc, or Synvisc-One before it will approve Euflexxa.
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 Euflexxa. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Euflexxa. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc, Synvisc, or Synvisc-One. The record does not show that these drugs would likely be less effective and/or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance for central venous access device placement, replacement or removal (77001) and the removal of a tunneled central venous catheter (36589) rendered by the out-of-network (OON) provider on October 21, 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 fluoroscopic guidance for central venous access device placement, replacement or removal (77001) and the removal of a tunneled central venous catheter (36589) rendered by the out-of-network (OON) provider on October 21, 2021.