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

We decided that the Plan does not have to pre-approve a maxillary partial denture.
You asked the Plan to pre-approve the maxillary partial denture. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is only covered 1 time in a 60 month time period. The Plan also says that you have already had this service done in that time period.
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, you are limited to 1 complete or partial denture every 5 years. The record shows that you received a complete maxillary denture on October 20, 2002 and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an electromyography (95938, 95940) provided June 30, 2020.
You asked the Plan to pay for the electromyography. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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 95938 & 95940 is Short-latency somatosensory evoked potential study. We find that CPT codes 95938 & 95940 are not supported in the medical record. Specifically, the medical records indicate that electromyography was performed but do not indicate that a Short-latency somatosensory evoked potential study was performed. Based on this information, we decided that Medicare rules for coverage of the electromyography have not been met. Therefore, we decided that the Plan does not have to pay for an electromyography (95938, 95940) provided June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 5, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that this item was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this patient did not receive video or telephonic visit by the ordering physician in order to warrant the code billed.
The Plan follows Medicare rules. Medicare rules say that a lumbar-sacral orthosis is subject to the criteria listed in the Medicare rules section. 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 lumbar-sacral orthosis. Our reviewer says that the requested item was not medically reasonable and necessary. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is
insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CARIS MI Profile testing.
You asked the Plan to pre-approve CARIS MI Profile testing. You say that the requested CARIS MI Profile testing is medically necessary. The Plan denied your request. The Plan says the requested CARIS MI Profile testing 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 CARIS MI Profile testing. Our reviewer says that the requested CARIS MI Profile testing is not medically necessary. Our physician reviewer found per the NCCN Guidelines all patients with metastatic colorectal cancer should have tumor tissue genotyped for RAS (KRAS and NRAS) and BRAF mutations individually or as part of an NGS panel. However, this enrollee has stage III disease and does not meet these criteria. The service is not reasonable or 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 CARIS MI Profile testing have not been met. Therefore, we decided that the Plan does not have to pre-approve CARIS MI Profile testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services provided on January 4,
2021, by an OON provider.
You asked the Plan to pay for these OON 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 payable.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the office visit and related services provided on
January 4, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the device. You say that you would like reconsideration because you suffer from worsening back pain. The Plan denied your request. The Plan says Medicare does not cover services that are experimental.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not have an indication for this device and the device is still considered experimental/investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on June 25, 2020.
You asked the Plan to pay for the drug testing. 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 payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for vision care provided on December 1, 2020.

You asked the Plan to waive the co-payment for vision care. You say that you disagree with the out-of-network charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 co-payment for in-network vision care and a $60 co-payment for out-of-network vision care.

You received vision care from an out-of-network provider on December 1, 2020. Therefore, you are responsible to pay $55, which is less than the $60 co-payment.

You have been asked to pay $55 for vision care. Vision care falls within the vision care 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 co-payment for vision care provided on December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on October 5, 2020.

You asked the Plan to pay for a pneumatic compression device. You say that the provider felt the requested item was necessary for the medical safety of the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 

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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on October 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility care after April 28, 2021.
You asked the Plan to pre-approve the Skilled Nursing Facility care. You say that you would like reconsideration because the requested care is medically necessary. The Plan denied your request. The Plan says this service is not medically necessary because your needs are not complex.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Skilled Nursing Facility care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as of April 28, 2021 you required custodial care.
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 Skilled Nursing Facility care have not been met. Therefore, we decided that the Plan does not have to pre-approve Skilled Nursing Facility care after April 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for intra-operative monitoring services (95861, 95870, 95938, 95955) provided on April 3, 2020.
You asked the Plan to pay for intra-operative monitoring services. You say that these services should be covered. The Plan denied your request. The Plan says these services were billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if a mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity. We looked at the file and Medicare rules. The services at issue were billed with the Mobile Unit POS code 15, but the records show that these services were provided by a mobile unit servicing an entity for which another POS code already exists. Based on this information, we decided that Medicare rules for coverage of intra-operative monitoring services have not been met. Therefore, we decided that the Plan does not have to pay for intra-operative monitoring services (95861, 95870, 95938, 95955) provided on April 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1851), a suspension sleeve (L2397), and supplies (A9900) provided on September 30, 2020.

You asked the Plan to pay for a knee orthosis, a suspension sleeve, and supplies. You say that these items should be covered. The Plan denied your request. The Plan says there is not a valid proof of delivery for these items.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. The submitted documentation does not include an itemized delivery invoice to confirm the specific billed supplies were delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1851), a suspension sleeve (L2397), and supplies (A9900) provided on September 30, 2020.
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 the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 in the Medicare rules section. We asked our 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 reviewer found based on the medical records provided 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 may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the abdominal ultrasound provided on November 19, 2020.
You asked the Plan to reduce the copayment for the ultrasound. You say that the provider's office told you there was only a $10 copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $75 copayment for Outpatient Diagnostic Tests, Ultrasound. You have been asked to pay a $75 copayment for the ultrasound. The ultrasound falls within the Outpatient Diagnostic Tests, Ultrasound 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 reduce the copayment for the abdominal ultrasound provided on November 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blepharoplasty surgery.
You asked the Plan to pre-approve blepharoplasty surgery. The Plan denied your request. The Plan says this
procedure is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that color photographs are required to support upper
eyelid surgery as 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 blepharoplasty surgery. Our reviewer
says that blepharoplasty surgery is not medically reasonable and necessary in this case. Our physician reviewer
found that the medical records provided do not establish the medical necessity and reasonableness as required
by the local coverage determination. No photographs were submitted for review. The elements of the coverage
determination are not satisfied. The requested service cannot be recommended at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of blepharoplasty surgery have not been met. Therefore, we decided that the Plan
does not have to pre-approve blepharoplasty surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because the member is medically stable and ready for transfer. The Plan denied your request. The Plan says the enrollee remains hemodynamically unstable for transfer.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound rendered on January 6, 2021.

You asked the Plan to waive the copayment for these services. You say that your copayment for a specialist is $40. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for Medicare-covered x-ray and ultrasounds.

Review of the file shows that you received an ultrasound on January 6, 2021. You have been asked to pay a $45 copayment for these services. These services fall within the Medicare-covered x-ray and ultrasounds benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The copayment you are being asked to pay is for a diagnostic ultrasound and not for specialist services. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound rendered on January 6, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can receive the care you need at a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided August 29, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the documentation is missing required information.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that the proof of delivery did not include an itemize order form or invoice to indicate the specific supplies; therefore, the billed supply code cannot be verified. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided August 29, 2020.