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

We decided that the Plan does not have to pay forthe medical services provided on October 16, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe nursing facility care (99309). You say that you would like reconsideration because this provider rendered medically necessary care in good faith.The Plan denied your request. The Plan says the provider did not receive authorization for the services rendered.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 providersonly in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on October 16,2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) knee orthosis (L1851) and suspension sleeve (L2397) provided October 8, 2019.You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) knee orthosis (L1851) and suspension sleeve (L2397) provided October 8, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT) for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary, as the location of
tumor is adjacent to the heart, proximal bronchial tree and great vessels. The Plan denied your request. The
Plan says that this is not reasonable and necessary under Medicare guidelines.
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 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 therapy. Our reviewer says that the
requested therapy is considered medically reasonable and necessary in this case. Our physician reviewer found
the radiation oncologist does not provide the prescribed dose - though presumably it is high dose per fraction as
it seems they plan to 'mimic' an SBRT plan. The other complicating factor is that no treatment plan is provided
showing that IMRT is superior to 3D conformal radiotherapy, with a clinically meaningful benefit. In other
words, one could consider a non-IMRT 3D conformal approach. However, based on the information provided
in the letter of appeal and clinical records, it is plausible that IMRT would provide a clinically meaningful
benefit based on the location of the tumor and the intent to deliver ablative-type doses. This treatment would
fall within accepted standards of care (based on NCCN guidelines).
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 therapy have been met. Therefore, we decided that the Plan has to preapprove
intensity-modulated radiation therapy (IMRT) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on August 20, 2019.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 nurse practitioner services provided on August 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extremity study rendered on November 15, 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 the billed MUE exceeds the allowed number of units.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 93970 is one. You billed two units of this code, exceeding the MUE. 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 extremity study rendered on November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on February 14, 2020.You asked the Plan to waive the copayment for the eye exam. You say that there were no medical services to diagnosis or treat the eye. You say that you received a routine eye exam.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 $45 for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye.You have been asked to pay a $45 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that your macular degeneration, pseudophakia, scotoma and retinopathy were checked during the eye exam. 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 eye exam provided on February 14, 2020.
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 your pneumatic compression device better suits the enrollee. The Plan denied your request. The Plan says there is no documentation of conservative measures or four weeks of home usage of a basic device.
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 fora Zoster (shingles) vaccine (90750) and administration (90471) provided on September 11, 2019.You asked the Plan to pay fora shingles vaccine and administration. You say that you were told this would be covered.The Plan denied your request. The Plan says this vaccine is only covered under Part D.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine and administration.Therefore, we decided that the Plan does not have to pay fora Zoster (shingles)vaccine (90750) and administration (90471) provided on September 11, 2019.Benefits for a shingles vaccine and administrationmay be available under Medicare Part D.Contactthe 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 the assembly and operation of a pump (99190) provided on November 26, 2019. You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. The rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three resin-based composites provided on February 3, 2020.
You asked the Plan to pay for the resin-based composites. You say that when the provider contacted your plan for your eligibility, the Plan did not disclose the six month waiting period rules. The Plan denied your request. The Plan says there is a six month waiting period for comprehensive services without evidence of continuous prior coverage at the time of enrollment in the Plan. The Plan also says that there is no evidence of calls from you or the provider to acquire benefit information prior to the services being rendered.
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, there is a six month waiting period for comprehensive services such as fillings, sealants, and extractions without evidence of continuous prior coverage at time of enrollment in the Plan. The records show that you enrolled in the dental plan as of December 1, 2019. You were not eligible for comprehensive services until June 1, 2020. Therefore, we decided that the Plan does not have to pay for the three resin-based composites provided on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 26, 2019.You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says the enrollee had the same orthosis provided by a different provider on August 22, 2019.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that D. Carswell had the lumbar-sacral orthosis (L0650) at the time the lumbar-sacral orthosis (L0650) was received. This lumbar-sacral orthosis (L0650) serves the same purpose as the lumbar-sacral orthosis (L0650)at issue and is still under reasonable useful lifetime. Based on the records provided, there is no indication the orthoses provided met Medicare coverage criteria for replacement at the time of issue.Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical pathology services provided on October 25, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe surgical pathology services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says there was no referral for the services received.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe surgical pathology services provided on October 25, 2019 by an out of network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the speech therapy rendered from November 26, 2019 to November 30, 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 the claims were not billed correctly.The Plan must follow Medicare rules. The rules say that outpatient speech therapy services must be billed with the GN modifier.We looked at the file and Medicare rules. The file shows that the claims were not billed with the required GN modifier. 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 speech therapy rendered from November 26, 2019 to November 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 17, 2018. You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 17, 2018
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on March 14, 2020 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you were recommended to this provider by your primary care physician.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that no referral is on file for 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 noexception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran office visit provided on March 14, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 additional home health physical therapy visits for a total of 20 visits.
You asked the Plan to pre-approve home health physical therapy visits. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested home health services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health physical therapy visits. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic pain. The enrollee has had prior therapy with increasing pain and has not progressed in walking pattern. The documentation indicates the enrollee can ambulate 125 feet but has fatigue and pain. The documentation does not reveal that the enrollee requires ongoing therapy beyond what was approved by the health plan. The enrollee does not need the unique skills of
a professional therapist to safely and effectively provide treatment. 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 establish, 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 home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 15 additional home health physical therapy visits for a total of 20 visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigations (D4921) and drugs or medicaments dispensed in the office for home use (D9630) provided on January 22, 2020 and January 23, 2020.You asked the Plan to pay for the gingival irrigations and drugs or medicaments dispensed in the office for home use. You say that these services were provided on an emergency basis because you were in pain.The Plan denied your request. The Plan says these services are not covered benefits.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 gingival irrigations (D4921) and drugs or medicaments dispensed in the office for home use (D9630) provided on January 22, 2020 and January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee on January 30, 2020 by a non-contracted provider.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the provider did not obtain prior authorization or a referral and the services were not urgent or emergent.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 inthis appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe services provided to the enrollee on January 30, 2020 by a non-contracted provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition to lower extremity prosthesis, user adjustable heel height (L5990).
You asked the Plan to pre-approve user adjustable heel height. You say that you have provided clinical documentation along with the physician order to assist with the review of this request. The Plan denied your request. The Plan says there is not Medicare or plan benefit for L5990 and therefore, this is not reasonable and necessary.
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 user adjustable heel height have not been met. Therefore, we decided that the Plan does not have to pre-approve addition to lower extremity prosthesis, user adjustable heel height (L5990)..