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

We decided that the Plan does not have to pay for the services provided on June 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.
The record shows that a claim for the services was not filed until March 29, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on June 11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven additional physical therapy visits.
You asked the Plan to pre-approve seven additional physical therapy visits. You say that the 7 additional physical therapy visits are medically necessary. The Plan denied your request. The Plan says the 7 additional physical therapy visits are not medically necessary.
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 seven additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based on the available records the requested therapy does not require the expertise of a skilled therapist. The requested therapy is repetitive application of compression garments and not a skilled service. The additional three visits approved by the health plan are sufficient to transition her care to a non-skilled caregiver. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of seven additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve seven additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 28, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed incorrectly.
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 the requested lab services not supported. Specifically, the billed codes are assigned a PC/TC
indicator of "9". This indicator means that the concept of a professional/technical component does not apply.
Therefore, the use of modifier -26 with these codes is not appropriate. Based on this information, we decided
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan
does not have to pay for the lab services provided on March 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on October 13, 
2020. 
 
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for the item at issue have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that a spinal orthosis is covered when the criteria in 
the Medicare rules section have been met. 
 
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 a lumbar-sacral orthosis. Our reviewer says 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on October 13, 
2020. 
 
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for the item at issue have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that a spinal orthosis is covered when the criteria in 
the Medicare rules section have been met. 
 
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 a lumbar-sacral orthosis. Our reviewer saysthat the item at issue is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the coverage criteria established by Medicare have been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan 
does not have to pay for a lumbar-sacral orthosis (L0650) provided on October 13, 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 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 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. It is not clear the enrollee would be able to fully benefit and/or participate in an 
IRF level of 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an interspinous spacer (22869).

You asked the Plan to pre-approve the insertion of an interspinous spacer. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 insertion of an interspinous spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous spacers are experimental. More research is needed to show safety and efficacy of these devices. 

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 insertion of an interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an interspinous spacer (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker purchased on August 22, 2020.

You asked the Plan to pay for this walker. You say that this walker should be covered by the Plan. The Plan denied your request. The Plan says the provider you obtained the walker from is not a Medicare eligible durable medical equipment provider.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a provider who is not a Medicare eligible provider. This walker was obtained from a provider who is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for a walker purchased on August 22, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve Orthovisc. You say that the requested Orthovisc is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Euflexxa, Supartz FX, Durolane, or Gelysn-3 first.
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 Orthovisc. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Euflexxa, Supartz FX, Durolane, or Gelysn-3 first before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable


We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested portable ventilator is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested portable ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a portable ventilator. Our reviewer says 
that the enrollee does not meet criteria for the requested portable ventilator. Our physician reviewer found a 
home ventilator is not medically necessary for this enrollee.  The enrollee has severe chronic obstructive 
pulmonary disease (COPD) with a recent episode of acute on chronic hypercarbic respiratory failure.  There is 
also a diagnosis of Obesity hypoventilation syndrome (OHS).  The enrollee has not been tried on BiPAP at 
home, and failure of BiPAP has not been demonstrated.  Medicare does not cover a ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on September 15, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 95955, 95908, and 95885 are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The definition of code 95908 is nerve conduction studies; 3-4 studies. The definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). 

We find that CPT codes 95955, 95908, and 95885 are not supported in the medical record. Specifically, there is no documentation of an EEG during nonintracranial surgery to support code 95955. There is no documentation of 3-4 nerve conduction studies to support code 95908. There is no documentation of needle electromyography to support code 95885.

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 testing services rendered on September 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2 Motion Orthotic Device.
You asked the Plan to pre-approve a MyoPro 2 Motion Orthotic Device. You say that the requested MyoPro 2 Motion Orthotic Device is medically necessary. The Plan denied your request. The Plan says the requested MyoPro 2 Motion Orthotic Device 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 a MyoPro 2 Motion Orthotic Device. Our reviewer says that the requested MyoPro 2 Motion Orthotic Device is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the requested MyoPro 2 Motion Orthotic Device meets Social Security Act, Section 1862(a)1(A) criteria for coverage as medically reasonable and necessary. Current guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a MyoPro 2 Motion Orthotic Device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro 2 Motion Orthotic Device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam, problem focused (D0140) provided May 5, 2021.
You asked the Plan to pay for the dental services. You say that you called the Plan and was told you would be covered for dental procedures and was sent a list of in-network providers. The Plan denied your request. The Plan says this service is not covered under the Plan 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. Services not listed under the Description of Benefits in the EOC is not covered.
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 limited oral exam, problem focused (D0140) provided May 5, 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 your care needs can be met in the skilled nursing facility setting.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for peripheral vascular disease and a right ankle infection. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on January 23, 2021.

You asked the Plan to pay for a pneumatic compression device. You say that this equipment was provided to the enrollee for surgery and should be covered by the Plan. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility.

Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on January 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 16, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these services ins included in payment to the facility.

The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services provided on January 16, 2021.