Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (CPT code L0650) provided to the enrollee on October 6, 2020.

You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

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.

The enrollee did not receive a video or telephonic visit by the ordering physician in order to warrant the code(s) billed. Furthermore, there are no claims on file with the ordering physician listed in the enrollee's claims history. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (CPT code L0650) provided to the enrollee on October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision services provided on October 7, 2020.

You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says you do not have out-of-network benefits.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

The file shows that you received routine vision care from an out-of-network provider. We looked at the file and the Plan's rules. Your plan only covers routine benefits from in-network providers. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the routine vision services provided on October 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a massage chair.

You asked the Plan to pre-approve a massage chair. You say that a massage chair has helped with circulation and pain. The Plan denied your request. The Plan says the chair is not medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a massage chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the CGM is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anterior resin-based composite of one surface (D2330) provided on December 21, 2020.

You asked the Plan to pay for the resin-based composite. You say that you are not able to pay for this procedure. The Plan denied your request. The Plan says the restoration benefit has a limit to two in a calendar year. The Plan also says that your history plus this request has gone over this limit.

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, restorations are limited to two of either codes D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2150 D2335, D2390, D2391, D2392, D2393, or D2394 per 1 calendar year. The record shows that you received two posterior resin-based composites of one surface on November 11, 2020, and your restorations benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the anterior resin-based composite of one surface (D2330) provided on December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on September 4, 2020.

You asked the Plan to pay for the knee orthoses (L1833LTRT) and suspension sleeves (L2397LTRT). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the orthoses are not supported in the medical records received.

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 knee orthoses (L1833LTRT) and suspension sleeves (L2397LTRT). Our reviewer says that the orthoses are not reasonable and medically necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. Claims for L1833 will be denied as not reasonable and necessary when the beneficiary does not meet the criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented.

The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

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 knee orthoses (L1833LTRT) and suspension sleeves (L2397LTRT) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on September 4, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visit provided on January 13, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy visit. You say that you have been seeing your therapist for over a year and she has been helping you. The Plan denied your request. The Plan says no prior authorization was obtained.

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 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 psychotherapy visit provided on January 13, 2021 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve lymphovenous bypass procedure to right arm (Current Procedural Terminology (CPT) code 38999), for the enrollee.

You asked the Plan to pre-approve lymphovenous bypass procedure to right arm (Current Procedural Terminology (CPT) code 38999). You say that this treatment is medically necessary. The Plan denied your request. The Plan says that these services are experimental.

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 lymphovenous bypass procedure to right arm (Current Procedural Terminology (CPT) code 38999). Our reviewer says that medical necessity has been established. Our physician reviewer found at issue is coverage of a lymphovenous bypass procedure to right arm. The enrollee is a 65-year-old woman with a history of breast cancer treated with surgery and sentinel lymph node biopsy, chemotherapy and radiation, who now has a diagnosis of lymphedema of the right upper extremity. The enrollee reported discomfort and heaviness, and difficulty wearing sweaters and long-sleeved shirts due to the swelling. Management of the lymphedema has included treatment by a lymphatic therapist, pneumatic therapy, and compression garments. Despite this treatment, the limb size has been increasing. It was determined that the enrollee would benefit from surgical management. Lymphovenous bypass is an accepted surgical treatment modality for those patients who have failed non-operative management. Medical necessity has been established.

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 requested service have been met. Therefore, we decided that the Plan has to pre-approve lymphovenous bypass procedure to right arm (Current Procedural Terminology (CPT) code 38999), for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmoscopy provided on November 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the ophthalmoscopy. You say that they provider performing services in a nursing home facility is not responsible to obtain authorization and the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 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 ophthalmoscopy provided on November 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve annual wellness visit (CPT code G0439) provided on December 9, 2020.

You asked the Plan to pre-approve the services. You say that you have not had an annual visit. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limits set in the subscriber agreement. The Plan states per your benefits, the service has a limit of once every 12 months. The same service was done on June 01, 2020 which was processed and paid by the plan.

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. Your EOC states that the service has a limit of once every 12 months. The same service was done on June 1, 2020, which was processed and paid by the plan. Therefore, we decided that the Plan does not have to pre-approve annual wellness visit (CPT code G0439) provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the genicular nerves for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of literature with true head-to-head comparisons with more standard treatments.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure, because there are still significant ongoing clinical trials to determine its place in the management of knee osteoarthritis. Therefore, this request is deemed not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the genicular nerves for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2332).

You asked the Plan to pay for the resin-based composite. You say that you cannot afford the services. The Plan denied your request. The Plan says you have reached the limit of 2 restorative procedures per calendar year.

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. The Plan has submitted evidence that you received 2 similarly coded services prior to this date of service. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2332).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services provided to the enrollee from July 13, 2020, through September 28, 2020, by a LMFT.

You asked the Plan to pay for mental health services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is not eligible to bill Medicare.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of mental health services have not been met. The National Provider Identifier (NPI) number entered on the billed provider claim was not found listed on the internet-based Physician Compare National Downloadable File List and provider is showing a specialty of Counselor Mental Health which is not a covered mental health service. Per the above guidelines we find that the Medicare rule for payment of this claim has not been met. Therefore, we decided that the Plan does not have to pay for mental health services provided to the enrollee from July 13, 2020, through September 28, 2020, by a LMFT.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction and non-intravenous conscious sedation provided on January 8, 2021.

You asked the Plan to pay for the extraction and non-intravenous conscious sedation. You say that these services were medically necessary. The Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction and non-intravenous conscious sedation provided on January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on December 28, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the home visit. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 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 home visit provided on December 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient surgical services/orthopaedic provided on January 20, 2020.

You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you were enrolled in Hospice on July 15, 2019 and are currently still enrolled. The Plan states your claims would be covered by original Medicare on the date of hospice election, until the first day of the following month in which Hospice was revoked. The Plan states the provider needs to submit their request for reimbursement to original Medicare for services rendered on January 20, 2020.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for outpatient surgical services/orthopaedic provided on January 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the wig purchased on November 13, 2020.

You asked the Plan to reimburse you for the wig. You say that you have prescription coverage, and this item should be covered. The Plan denied your request. The Plan says a wig does not serve a medical reason for use.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to reimburse you for the wig purchased on November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology services provided on July 20, 2020.

You asked the Plan to pay for the services provided. You say that the denial of the claim was not justified. The Plan denied your request. The Plan says the testing is considered unproven.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

We looked at the file and the rules. In this case, the records do not show that the ordered testing was diagnostic, prognostic, or correlates any test result with given interventions. The testing was provided for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the molecular pathology services provided on July 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) provided on November 25, 2020.

You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this service denied as a duplicate in error. The Plan denied your request.The Plan says per the NPI Registry, both providers have a specialty of (specialty, per NPI registry) and are in the same group practice, as indicated by the shared billing NPI of (billing NPI) on both claim submissions.

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 code 71045 is not supported in the medical record. Specifically, CPT code 71045 is a column II code to CPT code 32555 which has already been billed and paid to the same billing provider with the same NPI. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) provided on November 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).

You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee requires the device for when she returns home. The Plan denied your request. The Plan says total electric hospital beds are specifically excluded from coverage because the height adjustment feature is a convenience feature.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).