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

We decided that the Plan does not have to provide additional payment for the frames (V2020), progressive lenses (V2781) and bifocal lenses (V2203) provided November 19, 2021.

You asked the Plan to provide additional payment for the frames and progressive, bifocal lenses. You say that you are entitled to $150 for your eyeglasses. The Plan denied your request. The Plan says the $150 allowance has already been applied to the claim therefore no additional payment is due.

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 these services when up to a $150 allowance.

We looked at the file and the Plan's rules. You have been asked to pay a total of $484 ($755 total cost - $150 allowance = $605. $605 x 20% discount = $121. $605-$121 discount = $484 your cost) for the frames and lenses. Based on this information, we decided that the Plan's rules for coverage of the frames and progressive, bifocal lenses have not been met. Therefore, we decided that the Plan does not have to provide additional payment for the frames (V2020), progressive lenses (V2781) and bifocal lenses (V2203) provided November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster (shingles) vaccine rendered on January 8, 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 covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine rendered on January 8, 2021.

Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 13, 2021 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you were told that this provider was in-network. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 physician services provided on January 13, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot arch supports (CPT code L3030) provided on December 4, 2020.

You asked the Plan to pay for foot orthotics. You say that you spoke with the health plan prior to receiving your foot orthotics and were advised that the orthotics would be covered and that you also had a script from your doctor. The Plan denied your request. The Plan says they reviewed a phone call received from you on November 23, 2020, and they verified their customer service representative advised that the claim for foot orthotics would need to be submitted with a diabetic diagnosis for payment to be considered.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot arch supports (CPT code L3030) provided on December 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and more stable and only requires additional short-term acute care services for additional weaning and antibiotics which can safely be received at the current acute care facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the power wheelchair and accessories rendered on October 13, 2020.

You asked the Plan to waive the coinsurance for these services. You say that you paid the amount told to you by the associate at the time of delivery. The Plan denied your request. The Plan says the coinsurance was applied correctly.

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% coinsurance for in-network Medicare-covered durable medical equipment and related supplies.

Review of the file shows that you received a power wheelchair and accessories on October 13, 2020. You have been asked to pay a 20% coinsurance for these services, for a total of $1,395.78. These services fall within the in-network Medicare-covered durable medical equipment and related 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.

The file shows that you paid $1,040.05 at the time of delivery. The remaining contractual coinsurance amount to be paid is $355.73. Therefore, we decided that the Plan does not have to waive the coinsurance for the power wheelchair and accessories rendered on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for prostate cancer screening; PSA test (CPT code G0103) provided to the enrollee on October 12, 2020.

You asked the Plan to pay for the services. You say that no PSA has been completed since November 2, 2018. The Plan denied your request. The Plan says they confirmed with an office employee at the provider's office that they did order the PSA test, CPT code G0103, on January 17, 2020, and the results were reviewed by the doctor on January 20, 2020. The Plan states since the enrollee had already received the PSA lab in January and it was covered, the enrollee would not have been eligible until January 2021.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Your benefits state that one (1) PSA is covered every 12 months for men over 50 years old. Since the enrollee received a second PSA inside of the 12-month period, they are responsible for the full billed amount of $148.48 for the October 12, 2020 date of service. Therefore, we decided that the Plan does not have to pay for prostate cancer screening; PSA test (CPT code G0103) provided to the enrollee on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit for the evaluation and management of an established patient (CPT code 99335) provided to the enrollee on October 9, 2020, by an out-of-network provider.

You asked the Plan to pay for the services. You say that your doctor treated the enrollee at the facility, and they do not have authorization for this enrollee. The Plan denied your request. The Plan says they require the utilization of in network providers unless the plan pre-approves out of network services in non-emergent situations. The Plan states the authorization for out-of-network services was 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 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 domiciliary or rest home visit for the evaluation and management of an established patient (CPT code 99335) provided to the enrollee on October 9, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for CPAP supplies provided on September 21 to November 21, 2020.

You asked the Plan to pay for CPAP supplies. You say that the requested items are a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules state that continued use of a PAP device is covered only when there is objective evidence of adherence to use of the PAP device.

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the record does not contain objective evidence of compliance with a CPAP device. Therefore, we decided that the Plan does not have to pay for CPAP supplies provided on September 21 to November 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the muscle skin graft services coded 15734 provided on July 9, 2020.

You asked the Plan to pay for the muscle skin graft services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the billed services are not supported by the documentation.

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 15734 is muscle, myocutaneous, or fasciocutaneous flap; trunk.

We find that CPT code 15734 is not supported in the medical record. Specifically, the operative report did not include documentation of a muscle, myocutaneous, or fasciocutaneous flap, from the trunk; therefore, code 15734 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the muscle skin graft services have not been met. Therefore, we decided that the Plan does not have to pay for the muscle skin graft services coded 15734 provided on July 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on September 1, 2020.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was provided for screening purposes which is not covered.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services.

We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and injections provided by an out-of-network provider on December 11, 2019.

You asked the Plan to pay for the office visit and injections. You say that claims were paid in the past with no problem. You say that the claim should be reprocessed. The Plan denied your request. The Plan says in-network providers were available.

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 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 office visit and injections provided by an out-of-network provider on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a segmental pneumatic appliance (E0673) provided on August 31, 2020

You asked the Plan to pay for a segmental pneumatic appliance. You say that the requested care is a necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a segmental pneumatic appliance (E0673) provided on August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower extremity prosthesis addition (L5999) 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 medical studies have not proven that this device 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested device exceeds the enrollee's medical need and is considered a convenience item. Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

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 a lower extremity prosthesis addition (L5999) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for a therapeutic CGM (K0553) provided on December 17, 2020.

You asked the Plan to pay for CGM supplies. You say that the requested items are needed for the enrollee's care. The Plan denied your request. The Plan says rules for payment 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.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day or use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for supplies for a therapeutic CGM (K0553) provided on December 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study coded 95838 provided on September 28, 2020.

You asked the Plan to pay for the short-latency somatosensory evoked potential study. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 95838 is short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs.

We find that CPT code 95838 is not supported in the medical record. Specifically, the billed place of service of 15 (mobile unit) is not supported. the documentation shows that the enrollee was inpatient at the time services were provided. Based on this information, we decided that Medicare rules for coverage of the short-latency somatosensory evoked potential study have not been met. Therefore, we decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study coded 95838 provided on September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this device has deluxe features that exceed medical need and replaces, rather than improves the function of the arm.

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 is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.

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 the MyoPro Motion G orthotic device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 4, 2021 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that this is an independent lab. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says prior authorization was 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 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 lab work provided on January 4, 2021 by an out of network (OON) provider.