Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 5, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide 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 forthe medical services provided to the enrollee by anout-of-network provider on September 5, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Positron Emission Tomography (PET) scan (78815) provided on December 5, 2019.
You asked the Plan to pay for the PET scan. You say that the services were medically necessary. The Plan denied your request. The Plan says services were available in-network.
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 has network providers available who can provide 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 Positron Emission Tomography (PET) scan (78815) provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve12 further pain management visits for enrollee.You asked the Plan to pre-approvethese services. You say that there are no providers within 25 miles of the enrollee.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase 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 the services are medically necessary. Our physician reviewer found the enrollee had a diagnosis of colon cancer and has had multiple abdominal surgeryies. She is on a high doseof sufentanil and hydromorphone intrathecal mixture. The plan is to do opiate rotation and reduce the sufentil and increase the hydromorphone. Opiate rotation at these highdoses can be very challenging and require multiple interval re-programming steps, that cannot be accomplished once a month. The further visits are 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 these services have been met.Therefore, we decided that the Plan has to pre-approve12 further pain management visits for enrollee.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a wireless pulmonary artery sensor (CardioMEMS procedure).You asked the Plan to pre-approve CardioMEMS procedure. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has not tried/failed conservative treatment and further studies are needed to determine the safety and efficacy of this procedure.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 CardioMEMS procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found data obtained from a CardioMEMS device has been demonstrated in only 1 trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and it is not recommended in current guidelines for the treatment of heart failure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve implantation of a wireless pulmonary artery sensor (CardioMEMS procedure).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to enrollee on August 15, 2019 by an out of network (OON) provider.You asked the Plan to pay for the OON services. You say that the services were provided in good faith.The Plan denied your request. The Plan says prior authorization was required, but not obtained.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 has network providers available who can provide 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 OON services.Therefore, we decided that the Plan does not have to pay for the medical services provided to enrollee on August 15, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora diagnostic mammogram provided on January 2, 2020.You asked the Plan to waive the copayment fora diagnostic mammogram. You say that this was a preventative screening and you disagree with the charges.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 $20 copayment for each basic imaging service.The medical records show that you received a diagnostic mammogram on January 2, 2020. Therefore, you are responsible to pay the $20 copayment.  You have been asked to pay a $20 copayment for a diagnostic mammogram. A diagnostic mammogram 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 fora diagnostic mammogram provided on January 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device (MyoPro) for the enrollee.You asked the Planto pre-approve the device. You say that this is medically necessary.The Plan denied your request. The Plan says the current medical literature considers this device to experimental and investigational.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro Orthosis is not the most appropriate available supply or level of service for the patient considering potential benefits to the patient. It is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes for hemiparesis after stroke. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve thelong-termoutcomes for this patient, improve his hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase the patient's participation in bimanual activities. Additional controlled studies of the MyoPro requested device for upper extremity paralysis after stroke are needed with larger patient groups, consistent improvements of relevant outcome functional measures, and long term follow up.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met.Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device (MyoPro) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the bilateral knee orthoses (L1833) and suspension sleeves
(L2397) provided on November 27, 2019.
You asked the Plan to pay for the bilateral knee orthoses (L1833) and suspension sleeves (L2397). You say that
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the
items were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the billed service, L1833, was denied because two or
more diagnosis codes associated to it are mismatched per the ICD-10-CM Official Guidelines for Coding and
Reporting. The billed service, L2397, was denied because two or more diagnosis codes associated to it are
mismatched per the ICD-10-CM Official Guidelines for Coding and Reporting. Based on this information, we
decided that Medicare rules for coverage of the bilateral knee orthoses (L1833) and suspension sleeves (L2397)
have not been met. Therefore, we decided that the Plan does not have to pay for the bilateral knee orthoses
(L1833) and suspension sleeves (L2397) provided on November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) RT,LT and suspension sleeve (L2397) RT,LT provided December 9, 2019.
You asked the Plan to pay for the orthoses. You say that the diagnosis codes are properly coded and you would like the claims reconsidered for payment. The Plan denied your request. The Plan says the diagnosis code is inappropriately coded. The claim cannot be reprocessed for payment until a corrected claim is received.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) RT,LT and suspension sleeve (L2397) RT,LT provided December 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the basic metabolic panel billed for services provided on November 13, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed services cannot be verified.
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 80047 is Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea Nitrogen (BUN) (84520). We find that CPT code 80047 is not supported in the medical record. Based on the information provided, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the basic metabolic panel billed for services provided on November 13, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for OT services.
You asked the Plan to pay for the OT services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the record does not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide the treatments that have been appealed.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 OT services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the member's condition would not be expected to deteriorate as she was residing in an assisted living facility and had caregiver assistance available if needed for a maintenance home exercise program.
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 OT services have not been met. Therefore, we decided that the Plan does not have to pay for OT services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on October 30, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 has network providersavailable who can provide 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 forthe medical services provided to the enrollee by an out-of-network provider on October 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve immediate lower partial denture (D5140).You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration The Plan denied your request. The Plan says this requested service exceeds the benefit frequency limitations.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 requested service is covered 1 time every 5 years. Records show that this service was provided on 5/31/2019.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 immediate lower partial denture (D5140).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the transplant service food expenses.You asked the Plan to reimburse you for the transplant service food expenses. You say that the food expense is part of the transplant service and should be reimbursed.The Plan denied your request. The Plan says they have reimbursed you for the lodging expenses, on January 27, 2020, but food is not reimbursable.The Plan must follow Medicare rules. Medicare rules say that transportation and lodging must be provided by the Plan for transplant services at a distant location.We looked at the file and Medicare rules. Food expenses are not a covered benefit. Based on this information, we decided that Medicare rules for coverage of the transplant service expenses have not been met.Therefore, we decided that the Plan does not have to reimburse you for the transplant service food expenses.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing for congenital myotonia for the enrollee.You asked the Plan to pre-approve the testing. You say that this is medically necessary for the continued care of the myotonia congenital.The Plan denied your request. The Plan says this is considered experimental and investigational.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 casefile and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have myopathy, which may be genetic in nature. The enrollee is already trialing therapies (i.e. phenytoin, vitamins/supplements) for such a condition. There is no documentation as to how the requested genetic testing will ultimately affect the enrollee's treatment or disease management. As such, the documentation does not show the requested genetic testing to be medically necessary or reasonable.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 testing have not been met.Therefore, we decided that the Plan does not have to pre-approve genetic testing for congenital myotonia for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve plastic surgery services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided to the enrollee by a 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve plastic surgery services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 19101) provided on June 6, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed service cannot be verified.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 19101 is "Biopsy of breast; open, incisional".We asked our coding 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 use of CPT code 19101 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation of a biopsy of breast; open, incisional being performed on June 6, 2019. The medical records include a procedure note dated June 7, 2019. Since CPT 19101 cannot be validated for the billed date of service, June 6, 2019, it is not eligible for reimbursement consideration.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 19101) provided on June 6, 2019.