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

We decided that the Plan does not have to pay for the supplies rendered on February 12, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes and a status indicator of B is always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Billed procedure code 99072 (additional supplies and materials) has a status indicator of B and no separate Medicare payment. Codes S1015 (IV tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare. Therefore, we decided that the Plan does not have to pay for the supplies rendered on February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 27, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 drug testing rendered on January 27, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the services (62284) provided on September 15, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is a bundled code and is not separately payable.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan argues that code 62284 is bundled with code 62305 and cannot be paid on the same date of services. However, the records provided do not show that code 62305 was billed on September 15, 2020. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (62284) provided on September 15, 2020.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 11, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lipedema surgery to be performed by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that you do not want to have surgery within the Plan's network. The Plan denied your request. The Plan says the services can be performed by an in-network provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve lipedema surgery to be performed by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.

You asked the Plan to pre-approve this power mobility device (K0899). You say that you need this model because you have small doorways in your home. The Plan denied your request. The Plan says there is no medical reason why a standard power scooter would not meet your needs. You have been approved for a power scooter K0800.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The requested PMD is not coded by the PDAC. This means that Medicare rules for coverage of this model PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve this brand specific power mobility device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant (D4211) and sales tax (D9985) provided April 5, 2021.
You asked the Plan to pay for the gingivectomy or gingivoplasty and sales tax. You say that the gingivectomy was necessary to fill the tooth. The Plan denied your request. The Plan says these services are not covered under your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant (D4211) and sales tax (D9985) provided April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on November 27, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that When using 7th character "S", it is necessary to
use both the injury code that precipitated the sequela and the code for the sequela itself. The "S" is added only
to the injury code, not the sequela code.
We looked at the file and Medicare rules. In this case, using the 7th character "S" is not appropriate as a
primary diagnosis code. The "S" must be added to the injury code and sequenced first, followed by the sequela
code. 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 services provided on November 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for fluoroscopic guidance (77003) provided on March 31, 2021.
You asked the Plan to pay for fluoroscopic guidance. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with an appropriate primary code.
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 77003 is fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure). Use 77003 in conjunction with 61050, 61055, 62267, 62273, 62280, 62281, 62282, 62284, 64449, 64510, 64517, 64520, 64610, 96450.
We find that CPT code 77003 is not supported in the medical record. Specifically, this was not billed with an appropriate primary code. Based on this information, we decided that Medicare rules for coverage of fluoroscopic guidance have not been met. Therefore, we decided that the Plan does not have to pay for fluoroscopic guidance (77003) provided on March 31, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcranial magnetic stimulation.
You asked the Plan to pre-approve transcranial magnetic stimulation. You say that the requested transcranial magnetic stimulation is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested transcranial magnetic stimulation.
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 transcranial magnetic stimulation. Our
reviewer says that the enrollee does not meet criteria for the requested transcranial magnetic stimulation. Our physician reviewer found based on review of the records provided and utilizing the Medicare local coverage determination specifically for Transcranial Magnetic Stimulation ((TMS) (L33398) specifically requires the confirmed diagnosis to be Severe Major Depressive Disorder Single or Recurrent as well as resistance to treatment with pharmacologic agents as evidenced by lack of clinical significant response to 4 trials of pharmacologic agents in the current depressive episode from at least two different agent classes along with concurrent documented psychotherapy. Documentation presented does not specify what medications this enrollee has been taking during the present episode of depression. This enrollee had tried Prozac, clomipramine, Lexapro and Wellbutrin which she found intolerable. She had also taken lithium, Depakote, Lamictal, Seroquel, Zyprexa, Latuda, Risperdal and clozapine. There is no documentation of electroconvulsive treatment in the past. The enrollee has no clear documentation of psychotherapy. Utilizing the information from this enrollee that indicates this enrollee does have an indication for the requested Transcranial Magnetic Stimulation (TMS) this enrollee does not meet the LCD requirement for Transcranial Magnetic Stimulation (TMS) in the treatment of Bipolar Disorder Type I, Depressed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transcranial magnetic stimulation have not been met. Therefore, we decided that the Plan does not have to pre-approve transcranial magnetic stimulation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve specialist services. You say that you have already established care here. You say that you would like to continue to see this provider. The Plan denied your request. The Plan says these services can be safely provided in-network.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve specialist services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an outpatient surgery. You say that you cannot sleep with the CPAP machine and you would greatly benefit from this surgery. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy.
You asked the Plan to pre-approve the additional physical therapy. You say that you would like reconsideration because the additional physical therapy visits are necessary for you to be able to regain strength and prevent surgery due to your condition. The Plan denied your request. The Plan says you are stable to continue rehabilitation with the home exercise program and follow-up with your physician.
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 additional physical therapy. 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 further skilled therapy at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. 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 additional physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee admitted to acute care on 8/19/21 with inability to ambulate due to numbness/tingling of bilateral lower extremity due to spinal cord tumor and compression. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She tolerated her Thoracic Lumbar Sacral Orthoses (TLSO). Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. She was at a maximal assist level for bed mobility and transfers and non-ambulatory. She required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a necessity for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested level of care is not medically necessary.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee has no identifiable skilled nursing service needs. The enrollee does have identifiable skilled therapy service needs; however, the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702).
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro 2 is the best opportunity for regaining meaningful use of his left upper arm and has been deemed medically necessary for this enrollee by his provider. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgeon services provided on March 2, 2021.
You asked the Plan to pay for assistant surgeon services provided by a registered nurse. You say that the Plan should pay this claim. The Plan denied your request. The Plan says Medicare does not recognize the provider as a physician or nonphysician practitioner therefore the provider is not certified/eligible to be paid for this service.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS.
Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Also, a registered nurse is not eligible for payment by Medicare. Therefore, we decided that the Plan does not have to pay for assistant surgeon services provided on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office visits to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240).
You asked the Plan to pre-approve a shower chair. You say that the requested item is a medical necessity for
the enrollee. The Plan denied your request. The Plan says rules for coverage for durable medical equipment
have not been met.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on January 15, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that inpatient services must be billed with place of service (POS) code 21.
We looked at the file and Medicare rules. The file shows that the inpatient services were billed with POS code 11 for an office setting. 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 initial hospital care rendered on January 15, 2021.