Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for yoga classes requested on June 1, 2021.
You asked the Plan to pay for the services. You say that because of the pandemic, your usual yoga class switched to an online format. The Plan denied your request. The Plan says this is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only in a qualified fitness program under a full service health club or a fitness studio. The Plan's rules for coverage of gym benefits have not been met because the plan does not cover online fitness classes. Therefore, we decided that the Plan does not have to pay for yoga classes requested on June 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Rytary capsule.

You asked the Plan to pre-approve Rytary. You say that the enrollee has trialed and failed alternative drugs and has taken samples of the requested drug with good symptom management. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Rytary capsule.

Benefits for Rytary may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on August 23, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a
laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the
specimen was obtained in an office setting POS 11. Medicare billing criteria were not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, the claim cannot be paid as billed due to
an issue with the POS code. Medicare rules for coverage of these services have not been met. Therefore, we
decided that the Plan does not have to pay for lab services provided to the enrollee on August 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve L2-L4 posterior lumbar fusion and inpatient admission for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements are not met.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. She is noted to have tried physical therapy and medications. However, there is limited documentation indicating failure of any injection therapies. In addition, the provided imaging studies do not demonstrate instability in the lumbar spine. Nor is there documentation of inevitable potential impending/inevitable temporary intra-operative instability. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for inpatient L2-L4 posterior lumbar fusion is 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve L2-L4 posterior lumbar fusion and inpatient admission for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fitness equipment purchased on March 10, 2021.
You asked the Plan to pay for the services. You say that you were told that this would be reimbursed. The Plan denied your request. The Plan says this is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only in a qualified health club or fitness facility. The Plan's rules for coverage of gym benefits have not been met because the plan no longer covers fitness equipment in 2021. Therefore, we decided that the Plan does not have to pay for fitness equipment purchased on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on January 5, 2021 and billed under code 87631.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this is an administrative denial based on an inappropriate code. The Plan says there is a more appropriate code used by Medicare for the payment of this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, code 87631 is not the appropriate code used by Medicare for payment of this service. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on January 5, 2021 and billed under code 87631.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the prophylaxis, bitewing x-rays, oral exam, and 2 fillings. We decided
that the Plan does not have to pay for 1 additional filling.

You asked the Plan to pay for the dental services. You say that this provider is listed as in network on the Plan's
website. You also say that this provider cannot be out of your area as they are only 4 blocks from where you
live. The Plan denied your request. The Plan says the provider in this case is out of network.

We decided that the Plan has to pay for the prophylaxis, bitewing x-rays, oral exam, and 2 single-surface
fillings.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.

The provider in this case is listed as in network on the Plan's website. The file does not show that the Plan
provided notice that the dental services would not be covered. Under Medicare rules, this means the dental
services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the prophylaxis,
bitewing x-rays, oral exam, and 2 single-surface fillings.

We also decided that the Plan does not have to pay for the 2-surface filling.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are listed as covered, the
frequency limit has been reached with the approval of the 2 single-surface fillings. Therefore, we decided that
the Plan does not have to pay for the 2-surface filling.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99345) and a venipuncture and transfusion procedure (36415) provided on July 9, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for a home visit and venipuncture procedure. You say that you live in an independence living home and you are required to get a checkup. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a home visit (99345) and a venipuncture and transfusion procedure (36415) provided on July 9, 2020, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET scan with concurrent CT of the whole body for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the records show that a same study (or similar study) has already been approved.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found a biopsy was recommended in December 2020. A follow-up PET scan is not indicated when a CAT scan showing growth would be sufficient to assess for continued growth. The service is not 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 the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET scan with concurrent CT of the whole body for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device appliance provided on October 19, 2020.

You asked the Plan to pay for the pneumatic compression device appliance (E0673). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the device is not covered by Medicare to prevent deep vein thrombosis and payment for this service would have been included under the facility claim.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 

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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.

Therefore, we decided that the Plan does not have to pay for the pneumatic compression device appliance provided on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 27, 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 claim was billed incorrectly.
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 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on February 2, 2021.
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says the services billed are not manual manipulation of the spine and are not
covered by Medicare.
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 chiropractic
services provided on February 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF services provided after
June 22, 2021.
You asked the Plan to pre-approve continuation of SNF services provided after June 22, 2021. You say that you have muscle weakness and are a fall risk. You say that you need additional therapy to rebuild strength and to regain maximum functioning ability. The Plan denied your request. The Plan says your request does not
meet Medicare guidelines because you no longer require skilled services and the continuation of SNF care 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 continuation of SNF services provided after June 22, 2021. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, you no longer qualified for SNF coverage after
June 22, 2021. You did not have documented skilled nursing needs. You did not have documented skilled therapy needs. You were ambulating unlimited distances and tending to activities of daily living independently. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of your condition. At this point, your care needs were custodial and, as a practical matter, could be provided at a lower level of care (ex. home, assisted living, long term 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 continuation of SNF services provided after June 22, 2021 have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF services provided after June 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen equipment purchased on November 27, 2020.
You asked the Plan to pay for oxygen equipment. You say that this was a purchase of the equipment, not a
rental. The Plan denied your request. The Plan says the denial of payment for this item is correct, because
Medicare does not cover purchased oxygen equipment.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover purchased oxygen
equipment.
We looked at the file and Medicare rules. This oxygen equipment was purchased. Based on this information,
we decided that Medicare rules for coverage of oxygen equipment have not been met. Therefore, we decided
that the Plan does not have to pay for oxygen equipment purchased on November 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, chest (71045) provided January 26, 2021.
You asked the Plan to pay for the diagnostic services. You say that the provider performed the services in question and should be paid accordingly. Please review the attached documents and process for payment per the provider contract. The Plan denied your request. The Plan says the claim was received after the timely filing limitation.
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 diagnostic services was not filed until April 3, 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 radiologic examination, chest (71045) provided January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) provided on October 23, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that attached are your doctor's notes and the referral from the primary care physician. Please do not punish your doctor for the primary care physician's mistake. Please reprocess this claim. 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 the outpatient office visit (99203) provided on October 23, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services (36561) provided February 10, 2021.

You asked the Plan to pay for the surgical assistant services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed for the surgical assistant services does not match the service billed by the primary surgeon.

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 code 36561 is not supported in the medical record. Specifically, the procedure billed for the surgical assistant (36561) does not match the procedure billed by the primary surgeon (36563). Based on this information, we decided that Medicare rules for coverage of the surgical assistant services have not been met.

Therefore, we decided that the Plan does not have to pay for surgical assistant services (36561) provided February 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided February 5, 2021.
You asked the Plan to pay for the ambulance response. You say that you were not the one who called the ambulance and you were feeling better by the time it arrived. The Plan denied your request. The Plan says ambulances services are not covered when there is no transport.
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 February 5, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. The trip report in this case shows that you were feeling better and refused transport to the hospital and thus the wavier criteria is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this service is helpful for treatment of the health problem.
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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental and investigational procedure and is the subject of on-going clinical trials. She is not enrolled in a clinical trial. Therefore, the request is considered 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 the block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an expanded pharmacogenomic panel provided to the enrollee on February 1, 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 service was not supported by the procedure code billed on the claim.

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 CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 an expanded pharmacogenomic panel provided to the enrollee on February 1, 2021.