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

We decided that the Plan does not have to pay for surgical services (99153) provided on September 28, 2019.
You asked the Plan to pay for the surgical services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Specifically, the record indicates that these services were rendered on a different date of service than what was billed. The documentation submitted does not corroborate the documentation in the beneficiary's medical documentation. Therefore, we decided that the Plan does not have to pay for surgical services (99153) provided on September 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided to the enrollee out of network on December 17, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 Plan contract says chiropractic care requires referral and prior authorization. You are not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 chiropractic services provided to the enrollee out of network on December 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 29, 2020. You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) remains not supported. The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided to the enrollee out of network on December 10, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 Plan contract says chiropractic care requires referral and prior authorization. You are not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 chiropractic services provided to the enrollee out of network on December 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided January 27, 2020.
You asked the Plan to pay for the orthosis. You say that the medical records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records provided do not support the service billed.
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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee apparently has back pain, for which a back brace was provided. No detailed history, recent injury or surgery, associated symptoms, review of systems or physical examination, including weakness and/or deformity, has been documented. There is no evidence of diagnostic evaluation (i.e. x-rays) or prescription therapy provision/response (i.e. prescription meds, injections, PT/OT). Therefore, the documentation does not support the medical necessity or reasonableness of the provided service. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the custom fabricated abutment (D6057) and the abutment supported crown (D6058) provided on March 19, 2019.
You asked the Plan to reimburse you for the dental services. You say that the services you received should be covered under your medical plan. You say that the services you received were a result of an injury that you sustained after a fall. The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says the abutment and abutment supported crown are not listed as covered services under your dental coverage. The Plan also says that the services are not covered under the medical 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. The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Additionally, though the Plan offers a dental benefit in excess of Medicare coverage, the dental services that you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the custom fabricated abutment (D6057) and the abutment supported crown (D6058) provided on March 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 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 there has been no evaluation of affects since the home exercise program was prescribed. 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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has not completed three months of the home exercise program that was prescribed. Based on the medical records provided, Gelsyn-3 is not medically reasonable, reasonable, safe, or effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 injection for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on July 8, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the submitted code does not appropriately reflect the services provided by the PTA.
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 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 services. Our reviewer says that the use of CPT code 97162 is not supported by the records provided. Our physician reviewer found that the documentation submitted for CPT code 97162 is signed by a physical therapy assistant (PTA). CPT code 97162 is to be performed by a physician or other qualified health professional. Per CMS, PTA's are not permitted to perform evaluations, assessment procedures, or certain complex procedures; nor do they design plans of care or develop treatment plans. Accordingly, PTAs do not possess an independent "scope of practice" as do physical therapists. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond of a crown (D2920) provided on February 7, 2020.
You asked the Plan to pay for the re-cement or re-bond of a crown. You say that this claim should have been paid because the crown was for a front tooth that needed to be re-cemented in. The Plan denied your request. The Plan says this service is not covered under your 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 re-cement or re-bond of a crown (D2920) provided on February 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the tooth re-implantation (D7220) for teeth # 8 and 9, the initial periapical x-ray (D0220), the limited oral evaluation (D0140), and the panoramic x-ray (D0330) provided on January 2, 2020.
You asked the Plan to reimburse you for the dental services. You say that on New Year's Day you fell and hit your mouth directly on your patio. You say that your dentist was not available until January 6th. You say that your dentist got you an appointment with an oral surgeon. You also say that you had a follow up appointment with your regular dentist. The Plan denied your request. The Plan says the services that you received are dental in nature. The Plan also says that the dental services that you received are not covered under your medical plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the tooth re-implantation (D7220) for teeth # 8 and 9, the initial periapical x-ray (D0220), the limited oral evaluation (D0140), and the panoramic x-ray (D0330) provided on January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

The Plan does not have to pay for the hearing aids provided on October 11, 2019.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says that hearing aids ordered through a provider not in the vendor network is not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only ordered directly from the Plan vendor. We looked at the file and the Plan's rules. The file indicates you did not order the hearing aids from the Plan vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on October 11, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home-delivered meals.
You asked the Plan to pre-approve the meals. You say that you are diabetic and on dialysis, and can only eat certain food. The Plan denied your request. The Plan says this is not a supplemental covered benefit unless recently discharged from a hospital stay, and for 14 days only.
The Plan must follow Medicare rules. Plan rules state that home delivered meals are only covered following an inpatient hospital stay. There is no evidence that you are post inpatient hospital stay. Based on this information, we decided that Medicare rules for coverage of the meals have not been met. Therefore, we decided that the Plan does not have to pre-approve home-delivered meals.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy for the enrollee. You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says ten physical therapy sessions have been attended, with no major or significant response showing a likelihood that the problem will not get better.
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 the therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has had 10 prior sessions of therapy without evidence of significant objective functional improvement. The enrollee's functional level does not require ongoing skilled therapy. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist are 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 the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network chiropractic care provided to the enrollee from October 28, 2019 to November 13, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 contract with the Plan also states this type of care may require prior authorization. You are not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 out of network chiropractic care provided to the enrollee from October 28, 2019 to November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture provided from December 3, 2019 to December 14, 2019.
You asked the Plan to pay for acupuncture. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says your 2019 Plan contract clearly states acupuncture is not covered.
The Plan must follow Medicare rules. The 2019 rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pay for acupuncture provided from December 3, 2019 to December 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tradjenta.
You asked the Plan to pre-approve Tradjenta. You say that if left uncontrolled, elevated blood can cause damage to multiple organs. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tradjenta.
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 an LTACH is the most appropriate level of care for the enrollee. The Plan denied your request. The Plan says there are no skilled nursing needs or skilled therapy needs that require the requested level of care. The Plan says that the clinical information provided does not demonstrate that the requirements for coverage have been met. The Plan says that the enrollee's needs can safely be met at a lower level of care.
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 currently undergoing treatment at an acute care hospital (ACH) for renal failure and ascites. The enrollee subsequently developed respiratory distress requiring transient intubation/ventilation. The enrollee is no longer intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided November 11, 2019.
You asked the Plan to pay for the orthosis. You say that the records 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 wrist hand orthosis (L3916) provided November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic care.
You asked the Plan to pre-approve chiropractic care. You say that chiropractic care is medically necessary. The Plan denied your request. The Plan says there are no recent x-rays or medical records submitted by your primary care physician that show a chiropractic visit is required for manual manipulation to treat subluxation of the spine.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. The rules say only manual manipulation of the spine is covered. There were insufficient medical records submitted by your physician to support your need for chiropractic care at this time. Medicare rules for coverage of chiropractic care have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic care.