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

We decided that the Plan does not have to pay forlab services (HCPCS G0480 and CPT 80307) provided to the enrollee on May 2, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the submitted documentation does not itemize what tests are included in the panel; therefore, the billed codes 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 the denied codes:HCPCS G0480: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; 1-7 drug class(es), including metabolite(s) if performedCPT 80307:Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service (maps to 80301, 80302, 80303, 80304 and G0479). We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determineif 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 coded correctly. Our coding reviewer found the documentation submitted was reviewed. The documentation received did not include a signed physician order to indicate which tests are to be performed, and what is included in 8129 Premiertox12 autoflex .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 forlab services (HCPCS G0480 and CPT 80307) provided to the enrollee on May 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met at a less intensive level of care
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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional multiple therapies, however your functional level which is noted to be limited due to debility, occasional refusals, and NWB status do not require or indicate that this therapy must be in an IRF with an intensive level 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT) (E0766). You asked the Plan to pre-approve TTFT. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that TTFT is covered for the treatment of newly diagnosed GBM when specific criteria is met.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 TTFT. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have GBM (glioblastoma multiforme) therefore the requested use is not reasonable and 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 TTFT have not been met.Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT) (E0766).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown for tooth #13 (D2740).
You asked the Plan to pre-approve a crown for tooth #13. You say that the service is necessary. The Plan
denied your request. The Plan says the benefit has been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one crown per
tooth per 60 months.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of a crown for tooth #13 have not been met. The record shows that you received a
crown on tooth #13 on August 21, 2017. This means that you are not eligible for health plan coverage of a
crown on tooth #13 at this time. Therefore, we decided that the Plan does not have to pre-approve a crown for
tooth #13 (D2740).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.
You asked the Plan to pre-approve massage therapy. You say that massage therapy has helped with the
enrollee's pain and bring up phlegm. The Plan denied your request. The Plan says Medicare does not cover
massage therapy.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore,
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided from December 22, 2019 through December 24, 2019.You asked the Plan to waive the copayment for the ER visit. You say that you were admitted. You say that you shouldn't be asked to pay the copayment.The Plan denied your request. The Plan says the copayment 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 $120 copayment for emergency services in an emergency room.You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were only treated in the emergency room. 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 the ER visit provided from December 22, 2019 through December 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health and home physical therapy.
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level does not require or indicate that this therapy must be in an IRF with an intensive level 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits (92014) and determination of refractive state (92015) provided to the enrollee on November 18, 2019 by a non-participating provider.
You asked the Plan to pay for the services. You say that the services are medically necessary. The Plan denied your request. The Plan says you must receive your care from 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 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 ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits (92014) and determination of refractive state (92015) provided to the enrollee on November 18, 2019 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore buildup on tooth #9 (D2950).You asked the Plan to pre-approvecore buildup on tooth #9. You say that the services are necessary since you are in pain and are unable to eat properly.The Plan denied your request. The Plan says the requested 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 pre-approvecore buildup on tooth #9 (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device and appliances.
You asked the Plan to provide a pneumatic compression device (E0652) and appliances (E0667). You say that
the enrollee had increased pain and truncal swelling during the demo. The Plan denied your request. The Plan
says there was no good faith trial or evidence of truncal swelling.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
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, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to provide a pneumatic compression device and
appliances.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc 30mg injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that the enrollee has always had Orthovisc in the past, and receives over six months of relief. The Plan denied your request. The Plan says there is no documentation of a step 1 drug, such as Hyalgan, Hymovis, or Synvisc, being tried within the last 365 days.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the provided medical records do not document a trial and failure of the plan's required step therapy drugs. The provided medical records do not indicate that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc 30mg injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the diabetic shoes provided on January 28, 2020.
You asked the Plan to pay for the diabetic shoes. You say that the Plan approved the shoes. The Plan denied
your request. The Plan says that you were not a member when the shoes were purchased.
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 looked at the file and Medicare rules. You were a member of this Plan when the shoes were prescribed,
fitted, approved, and authorized. Based on this information, we decided that Medicare rules for coverage of the
diabetic shoes have been met. Therefore, we decided that the Plan has to pay for the diabetic shoes provided on
January 28, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6539.
You asked the Plan to pre-approve the compression stockings. You say that your cardiologist has stated that you will need to wear compression stockings from now on. The Plan denied your request. The Plan says this specific type of stockings is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6539 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6539.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumbar injection provided on January 28, 2020.You asked the Plan to waive the copayment for the lumbar injection. You say that this was an injection not a surgery. You say that you shouldn't be charged the outpatient surgery copayment.The Plan denied your request. The Plan says the copayment 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 $200 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $200 copayment for the lumbar injection. The lumbar injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The lumbar injection is considered a surgical injection. 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 the lumbar injection provided on January 28, 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.
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. 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 powered upper extremity range of motion assist device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a muscle transfer (23395) provided on January 8, 2020.You asked the Plan to pay for the muscle transfer. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the service 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 code 23395 is muscle transfer, any type, shoulder or upper arm; single.We asked our coder 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 muscle transfer. Our reviewer says that CPT code 23395 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not state that a muscle transfer was performed during this procedure.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 muscle transfer have not been met.Therefore, we decided that the Plan does not have to pay fora muscle transfer (23395) provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

Plan to pay for OON acupuncture services. You say that you were not aware your referral had
expired. The Plan denied your request. The Plan says these 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 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 acupuncture services (99202, 97810, 97811)
provided on January 31, 2020 to February 4, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation (E2300) and power standing feature (K0108).You asked the Plan to pre-approvea power seat elevation and power standing feature. You say that the requested items are necessary.The Plan denied your request. The Plan says the items are not primarily medical in nature. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation and power standing feature have not been met.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation (E2300) and power standing feature (K0108).