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

We decided that the Plan does not have to pay for the drug testing rendered on October 28, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on October 28, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on November 7, 2019 to December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON psychotherapy services. You say that the enrollee was under the impression you sessions would be covered. 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 psychotherapy services provided on November 7, 2019 to December 19, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device (E0652).
You asked the Plan to provide a pneumatic compression device. You say that the enrollee's swelling cannot be effectively treated with a standard pump. The Plan denied your request. The Plan says the enrollee has not underwent a trial with a basic pump and there is no information of swelling extending into the trunk, abdomen, or chest.
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 (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by a chiropractor on February 18, 2020.You asked the Plan to pay for office visit. You say that you believe this treatment was well beyond what would be considered massage.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered by Medicare or the Plan when performed by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for an office visit provided by a chiropractor on February 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services rendered from January
8, 2019 to December 3, 2019.
You asked the Plan to pay for these services. You say that you thought supplemental policies covered this
provider. The Plan denied your request. The Plan says the provider type is not covered.
The Plan must follow Medicare rules. The rules say that a marriage family therapist is not eligible to participate
in Medicare.
We looked at the file and Medicare rules. The file shows that the services at issue were rendered by a licensed
marriage family therapist. Therefore, we decided that the Plan does not have to pay for the outpatient mental
health services rendered from January 8, 2019 to December 3, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued outpatient physical therapy visits.You asked the Plan to pre-approvephysical therapy. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for these servicesis correct, because the enrollee has been afforded adequate therapy sessions and can now proceed with a home-based program.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 pre-approve physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has a chronic balance issuedating back to at least October 2019. The enrollee has made some progress in therapy, but the records do not indicate he requires the unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to be performed only by a therapist or under the supervision of a therapist. The enrollee has had extensive therapy and was trained in a home exercise program. The requested services are not part of a maintenance program and the specialized skill, knowledge, and judgment of a qualified therapist is not required to established, design, and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued outpatient physical therapy visits
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on January 22, 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 procedure code 70450 is not separately payable.The rules say that, for edits with a modifierindicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 70450 and 70496. Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine examination provided on January 27, 2020.
You asked the Plan to pay for routine exam. You say that there is no difference between a regular physical examination and a Department of Transportation (DOT) examination. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered by Medicare when performed for the Department of Transportation (DOT).
The Plan must follow Medicare rules. Medicare rules say that routine physical examinations required by third parties such as government agencies are excluded from coverage. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of routine exam have not been met. Therefore, we decided that the Plan does not have to pay for a routine examination provided on January 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on November 5, 2019.You asked the Plan to pay for the x-ray services. 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 71045 is radiologic examination, chest; single view.We find that CPT code 71045 is not supported in the medicalrecord. Specifically, the documentation shows that an exact duplicate of the claim has been previous processed and paid The documentation does not support that the service was performed more than once for this date of service. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met.Therefore, we decided that the Plan does not have to pay forthe x-ray services coded 71045 provided on November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 laboratory services provided on January 7, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe anesthesia services rendered on November 18, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 00670 is not supported.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 00670 is anesthesia for extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures).We find that CPT code 00670 is not supported in the medical record. Specifically, there is no anesthesia report to confirm that the services were rendered. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe anesthesia services rendered on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite - two surfaces, posterior (D2392) provided on February 27, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for resin-based composite - two surfaces, posterior (D2392) provided on February 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan (J9312).
You asked the Plan to pre-approve Rituxan. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the safety and efficacy of this drug have not been shown in this condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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-approve Rituxan. Our reviewer says that review of compendia does not support FDA approval or off-label use of Rituxan for this diagnosis. Our physician reviewer found that without the support of the compendia, medical necessity cannot be determined. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan (J9312).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive oral exam (D0150) and full mouth x-rays (D0210) completed March 13, 2020 that was provided March 13, 2020. You asked the Plan to pre-approve the dental services. You say that you have already received the services and do not understand why you would have to pay out of pocket. The Plan denied your request. The Plan says the services received on March 13, 2020 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 oral exams are covered once every 6 months and the x-rays are covered once every 12 months. The records show these services were provided January 6, 2020. You would not be eligible for the exam until July 6, 2020 and the full mouth x-rays until January 5, 2021. 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 comprehensive oral exam (D0150) and full mouth x-rays (D0210) completed March 13, 2020 that was provided March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography services coded 95870 provided
on April 24, 2019.
You asked the Plan to pay for the needle electromyography services. 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 95870 is needle electromyography; limited study of
muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal,
cranial nerve supplied muscles, or sphincters.
We find that CPT code 95870 is not supported in the medical record. Specifically, the documentation submitted
does not support the units billed (2 units). Based on this information, we decided that Medicare rules for
coverage of the needle electromyography services have not been met. Therefore, we decided that the Plan does
not have to pay for the needle electromyography services coded 95870 provided on April 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea home blood pressure cuff.You asked the Plan to providehome blood pressure cuff.You say that you are unable to go to your doctor's office so you need to check your blood pressure at home.The Plan denied your request. The Plan says you are not on home dialysis or require ambulatory blood pressure monitoring.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to providea home blood pressure cuff.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea semi-electric hospital bed.You asked the Plan to pre-approve a semi-electric hospital bed. You say that you do not have a bed and are tired of sleeping on the sofa. The Plan denied your request. The Plan says you are independent in bed mobility and your needs can be met with a standard bed.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.We looked at the file and Medicare rules. Your physical therapy evaluation does not support a medical need for a hospital bed. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for 3D rendering with interpretation (76337) provided on November 21, 2019.
You asked the Plan to pay for the 3D imaging. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the use of 3D-rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, or other tomographic modality with image postprocessing is not covered separately by Medicare if it is contained in the authorized radiologic 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 pay for the 3D imaging. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found three dimensional rendering codes were not necessary as the additional image was not necessary for a complete depiction of an abnormality from the 2D study or for surgical planning. 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 3D imaging have not been met. Therefore, we decided that the Plan does not have to pay for 3D rendering with interpretation (76337) provided on November 21, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on February 13, 2020.
You asked the Plan to waive the copayment for the endoscopy. You say that this copayment seems too high. 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 $245 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $245 copayment for the endoscopy. The endoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 the endoscopy provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these 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 for an office visit provided on October 25, 2019 by an out of network (OON) provider.