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

We decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on November 19, 2019.
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare says tests with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.
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 testing. Our reviewer says that the services at issue in this case are not medically reasonable or necessary. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). In general, screening tests are permitted in limited circumstances and must be accompanied by proper documentation and coding. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D Oral/facial photographic images obtained intraorally or extraorally (D0350) provided on January 14, 2020.
You asked the Plan to pay for these services. You say that you need this to maintain good health. The Plan denied your request. The Plan says that this is not covered under your dental 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. Therefore, we decided that the Plan does not have to pay for the 2D Oral/facial photographic images obtained intraorally or extraorally (D0350) provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 19,
2017.
You asked the Plan to waive the copayment for the office visit. You say that the provider should be paid. 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 $15
copayment for provider and professional services at an in-network PCP's office.
You have been asked to pay a $15 copayment for the office visit. The 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 the office visit provided on September 19,
2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Endosteal implants (D6010) provided January 7, 2020 by an
out-of-network provider.
You asked the Plan to pay for the implants. You say that the service was medically necessary. The Plan denied
your request. The Plan says dental services provided out-of-network are not covered.
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 because they were provided out-of-network. Therefore, we decided that
the Plan does not have to pay for Endosteal implants (D6010) provided January 7, 2020 by an out-of-network
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete maxillary/mandibular dentures (D5110 and D51230)
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit for this service 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 dentures once every five years. The file shows that dentures were received on 10/12/18 and 1/10/20. These services were received less than five years ago. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve complete maxillary/mandibular dentures (D5110 and D51230)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on December 27, 2019.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
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. The medical records do not mention or support medical necessity for the orthoses.
Based on this information, we decided that Medicare rules for coverage of the shoulder-elbow-wrist-hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on December 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee has not been able to walk 100 meters without breaks or falling. The Plan denied your request. The Plan says there are no medical issues that require supervision by an inpatient rehab physician three times a week.
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 physician reviewer found that the enrollee requires standby assist to sit up, minimal assist to standup, and minimal assist to walk using a wheeled walker. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Therefore, the requested services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for subsequent hospital care (99232) provided on January 13, 2020. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says that services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code. 
 
The Plan must follow Medicare rules. Medicare rules say that all line items for the same beneficiary, same NPI, and same date of service shall be subject to NCCI procedure-to-procedure (PTP) edits. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have been met. Specifically, the provider who rendered this service has a separate NPI than the provider who rendered the column I procedure. NCCI PTP edits are not appropriate in this case. Therefore, we decided that the Plan has to pay for subsequent hospital care (99232) provided on January 13, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 3, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
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 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro upper extremity range of motion assist device.
You asked the Plan to pre-approve MyoPro upper extremity range of motion assist device. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is
not medically necessary.
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 MyoPro upper extremity range of
motion assist device. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found the enrollee suffered an ischemic stroke in
2014 with left spastic hemiparesis. The MyoPro Orthosis is not the most appropriate available supply or level
of service for the enrollee in question considering potential benefits to the enrollee. It is not known to be
effective, based on scientific evidence, professional standards and expert opinion, in improving health
outcomes. The MyoPro is not the standard of care for this enrollee's condition. 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 enrollee, improve the enrollee's hemiparetic arm
function, or be safe for long term use. There is insufficient evidence in the literature that this device will
increase the enrollee's participation in bimanual activities. It is not medically necessary and reasonable for this
enrollee to have a MyoPro upper extremity range of motion assist device as requested.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of MyoPro upper extremity range of motion assist device have not been met.
Therefore, we decided that the Plan does not have to pre-approve MyoPro upper extremity range of motion
assist device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 11, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on December 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 4, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the place of service
on the claim must reflect the location where the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that the POS code reflects the actual place where the
beneficiary receives the face-to-face service.
We looked at the file and Medicare rules. The claim provided lists the POS as an independent laboratory (Code
81). However, the documentation provided does not show the specimen was taken at an independent lab. Based
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that
the Plan does not have to pay for the lab services provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair services coded 12041 provided on July 31, 2019.
You asked the Plan to pay for the repair 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 12041 is repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less. We find that CPT code 12041 is not supported in the medical record. Specifically, the documentation submitted did not indicate that repair, intermediate, wounds of neck, hands, feet or external genitalia; 2.5 cm or less was performed. Therefore, code 12041 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the repair services have not been met. Therefore, we decided that the Plan does not have to pay for the repair services coded 12041 provided on July 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 28, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says that the claim
processed correctly.
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 does not cover dental
services provided out-of-network.
We looked at the file and Medicare rules. The file indicates you received these services from an out-of-network
provider. Based on this information, we decided that the Plan's rules for coverage of the dental services have
not been met. Therefore, we decided that the Plan does not have to pay for the dental services provided on
January 28, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a Gel-One injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that there are currently no clinical indications for injections of the knee.
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 the injection. Our reviewer says that the requested injection is medically reasonable and necessary. Our physician reviewer found the enrollee is noted to have osteoarthritis of the knee. The enrollee has tried conservative therapies, but his symptoms have continued. The documentation shows a medically accepted indication for the use of a hyaluronic acid injection. Use of the requested drug is medically necessary and 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 injection have been met. Therefore, we decided that the Plan has to pre-approve a Gel-One injection for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP rental provided on December 3, 2019.
You asked the Plan to pay for the CPAP rental. You say that the Plan should pay this claim. The Plan denied your request. The Plan says they have paid 13 consecutive payments and the ownership now passes to the enrollee.
The Plan must follow Medicare rules. Medicare rules say that DME MACs continue to pay rental fees not to exceed a period of continuous use of 13 month and ownership of the equipment passes to the beneficiary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP rental have not been met. Therefore, we decided that the Plan does not have to pay for the CPAP rental provided on December 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc for the enrollee.
You asked the Plan to pre-approve Synvisc. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.
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 Synvisc. Our reviewer says that Synvisc is not medically reasonable and necessary for the enrollee in this case. The enrollee has not trialed viscosupplemental treatment with Orthovisc. Step therapy, as outlined by the plan, requires Orthovisc and Monovisc (tried/failed) be trialed first. The documentation does not outline contraindications or reasons the additional medication was not considered. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Synvisc. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a blepharoplasty (15822) provided on December 20, 2019.
You asked the Plan to pay for the blepharoplasty. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the 2 billed units of this service were greater
than the Medicare MUE value set for this code.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 15822 is 1. You billed 2 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of the blepharoplasty have not been met.
Therefore, we decided that the Plan does not have to pay for a blepharoplasty (15822) provided on December
20, 2019.
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 this level of care is needed The Plan denied your request. The Plan says IRF care is only by Medicare to be reasonable and necessary if the enrollee meets all of the requirements.
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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee is already ambulating more than 100'. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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.