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

We decided that the Plan does not have to pay for chiropractic services received on January 16, 2020.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no clinical documentation that these services were for the treatment of
subluxation.
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.
Despite multiple attempts, records were not received concerning these services. There is no way to determine if
the treatment was manual manipulation of the spine to treat a subluxation. 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 chiropractic services received on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cushions or overlay.
You asked the Plan to pre-approve the custom seat cushion (E2609), foam overlay (K0108), and custom back
cushion (E2620). You say that the enrollee has poor balance and trunk control. The Plan denied your request.
The Plan says the custom back cushion is included in the nursing home per diem and the overly and seat
cushion are not medically necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF to be a home.
Records show that the custom seat cushion (E2609), foam overlay (K0108), and custom back cushion (E2620)
are being requested for use in a SNF. Therefore, we decided that the Plan does not have to pre-approve the
cushions or overlay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoride varnish application (D1206) provided on February 6, 2020.
You asked the Plan to pay for the fluoride varnish application (D1206). You say that the dentist did what was needed. 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 pay for the fluoride varnish application (D1206) provided on February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the
enrollee on September 12, 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 records do not support the services 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, the CPT Code Manual definition of HCPCS code G0482 is "Drug test(s), definitive, utilizing (1)
drug identification methods able to identify individual drugs and distinguish between structural isomers (but
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-
21 drug class(es), including metabolite(s) if performed."
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 no
provider records correlating to the date of service have been submitted for review. Therefore, there is no
documentation of a provider's concern for drug abuse/misuse. There is no evidence that a UDS was completed
and the results reviewed prior to ordering the UDT. There is no evidence that the UDT was tailored to the
enrollee's addictions and/or medications. Therefore, the documentation does not support that the UDT was
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing services (HCPCS G0482) provided to the enrollee on September 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 30, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed
code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services provided on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says a PCD for the purpose of prevention of venous thromboembolism (E0676) is not covered by Medicare or the Plan.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 pre-approve a pneumatic compression device (E0676).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee from January 13, 2020 through January 14, 2020. You asked the Plan to pay for the services. You say that the claims should be reprocessed. The Plan denied your request. The Plan says the member was enrolled in hospice at the time of services. The Plan states per Medicare guidelines, the member's services should be billed under Original Medicare. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was in hospice from January 4, 2020 through January 13, 2020 and January 19, 2020 through February 2, 2020. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee from January 13, 2020 through January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing services provided on October 7, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe genetic testing services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says pre-authorization was not provided before rendering services.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 forthe genetic testing services provided on October 7, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care (99309). You say that you would like reconsideration because the provider rendered medically necessary care in good faith. The Plan denied your request. The Plan says utilization of network providers is required unless the Plan pre-approves out-of-network services in non-emergent situations.
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 medical services provided on January 28, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

You asked the Plan to pre-approve the surgical extraction of tooth #2, #3, #6, #7, #10, #12 and #13. You say that the records provided support the need for the requested extractions. The Plan says that the requested extractions are not medically reasonable and necessary. We decided that the Plan has to pre-approve the surgical extraction of tooth #7 and #13. Medicare generally does not cover dental services. However, the Plan offers a dental benefit hat 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 extractions are only covered under this benefit when they are medically reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-authorize the dental extractions. Our physician reviewer found that the provided panoramic and periapical x-rays show that tooth #7 and #13 are broken below the level of the gum line. Our physician reviewer found that tooth #7 and #13 would need and be properly coded for surgical removal. Therefore, we decided that the Plan has to pre-approve the surgical extraction of tooth #7 and #13. We also decided that the Plan does not have to pre-approve the surgical extraction of tooth #2, #3, #6, #10, and #12. 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 extractions are only covered under this benefit when they are medically reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-authorize the dental extractions. Our physician reviewer found that the provided panoramic and periapical x-rays indicate that teeth #3 and #10 are not present in the arch or just cannot be seen on the provided x-rays. Our physician reviewer found that tooth #2, #6, and #12 has sufficient coronal structure present, such that a standard and non-surgical extraction would be initially indicated. Our physician reviewer found that, given the presentation of the remaining teeth, there would be no medical necessity for surgical removal of tooth #2, #3, #6, #10, or #12. Therefore, we decided that the Plan does not have to pre-approve the surgical extraction of tooth #2, #3, #6, #10, or #12. 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 reduce the copayment for the EKG provided on January 27, 2020. 
 
You asked the Plan to reduce the copayment for the EKG. You say that you should only be responsible for $0.76 for the EKG because the Plan paid $3.78. The Plan denied your request. The Plan says you have been 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 $25 copayment for other Medicare-covered outpatient diagnostic procedures and tests.  
 
You have been asked to pay a $15 copayment for the EKG, which is less than the standard copayment amount. The EKG 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 reduce the copayment for the EKG provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2, Motion G Motion Orthotic Device.
You asked the Plan to pre-approve a powered upper extremity range of motion assist device (L8702). You say
that this device would restore function to the dysfunctional arm and the ability to perform activities of daily
living. The Plan denied your request. The Plan says this device has deluxe features that exceed your need and
replaces, rather than improves the arm function.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary, and are experimental and investigational, are not covered.
We looked at the file and Medicare rules. There is insufficient medical record information submitted to show
this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by
Medicare. The requested limb orthosis continues to be denied because of insufficient evidence of its
effectiveness. Based on this information, we decided that Medicare rules for coverage of a powered upper
extremity range of motion assist device (L8702) have not been met. Therefore, we decided that the Plan does
not have to pre-approve a MyoPro 2, Motion G Motion Orthotic Device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on April 8, 2020.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 10, 2020.
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 Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic profiling for NSCLC.
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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory screening panel rendered on March 24, 2020.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal 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 the respiratory
screening panel rendered on March 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from March 20, 2018 through August 16, 2019.You asked the Plan to pay for the dental services. You say that dental treatments and reconstruction resulting from mouth cancer are covered. You say that your infection falls within this category or situation.The Plan denied your request. The Plan says you do not have supplemental dental coverage under your Plan.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay for the dental services provided from March 20, 2018 through August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on December 30, 2019.
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit 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 $15 copayment for standard primary care provider visits. The medical records show that you received services beyond an annual wellness visit on December 30, 2019. Therefore, you are responsible to pay the $15 copayment. You have been asked to pay a $15 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit provided on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a donning and doffing aid.You asked the Plan to pre-approve a donning and doffing aid. You say that without this device you are unable to put on your compression stockings.The Plan denied your request. The Plan says this device does not meet the Medicare definition of DME and is not payable by Medicare.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve a donning and doffing aid.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 enrollee recently suffered a stroke. The enrollee is not in any distress and is able
to feed herself. The documentation does not support that the complexity of the enrollee's nursing, medical and
rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation
care. While the enrollee may benefit from further physical therapy and occupational therapy, there is no need
for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an
interdisciplinary approach to rehabilitation care. Therefore, the enrollee's care needs can be met at a lower 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.