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

We decided that the Plan does not have to pre-approve Intradialytic Parenternal Nutrition (IDPN).
You asked the Plan to pre-approve IDPN. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical records show no significant weight loss, a body mass index of 29, and no laboratory test results, or other documentation of malnutrition.
The Plan follows Medicare rules. Medicare rules say that parenteral nutrition is considered reasonable and necessary for a patient with severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the patient's general condition.
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 IDPN. Our reviewer says that IDPN is not medically reasonable and necessary in this case. You receive dialysis and have a low serum albumin. You do not have a malabsorptive state. The medical record does not indicate that intestinal tract pathology exists. Our physician reviewer found that your condition does not meet Medicare criteria for IDPN. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IDPN have not been met. Therefore, we decided that the Plan does not have to pre-approve Intradialytic Parenternal Nutrition (IDPN).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive drug testing provided on August 21, 2020.
You asked the Plan to pay for the testing services. You say that the documentation supports the services. The Plan denied your request. The Plan says the billed code cannot be verified.
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 80307 is presumptive drug testing. We find that CPT code 80307 is not supported in the medical record. The records do not include an order for the testing at issue. The records do not clearly document the intent for the services to be performed. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive drug testing provided on August 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames (V2020) and progressive lenses (V2781) provided December 28, 2019, by an out-of-network (OON) provider.
You asked the Plan to pay for the frames and progressive lenses. You say that you were told this provider was in-network. The Plan denied your request. The Plan says the routine eyewear was provided OON and therefore is not covered.
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 Plan covers these services when provided by the Plan's specified vision provider. We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of the frames and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020) and progressive lenses (V2781) provided December 28, 2019, by an out-of-network (OON) provider.
Your complaint about potentially receiving misinformation and confusing information from the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the core build up (D2950), the pulp cap (D3120), the crown (D2740), and the filling (D2332) provided on February 12, 2021.
You asked the Plan to pay the full amount for the dental services. You say that dental is included in your medical insurance. You say that you received a bill for $1,459. You say that all of the services were medically necessary. You also say that the services should be covered in full. The Plan denied your request. The Plan says core build up and pulp cap are not listed as covered services. The Plan says that the provider in this case is out of network.
The Plan says that for dental services performed out of network the coinsurance level will apply to the average negotiated in network fee schedule (INFS) in your area. The Plan also says that you are responsible for the difference between the INFS and dentists' charged fees when visiting an out of network dentist.
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, core build up and pulp cap are not among those covered under this benefit. The Evidence of Coverage says that crowns have a 75% coinsurance when performed out of network, and fillings have a 55% coinsurance when performed out of network coinsurance. Additionally, out of network providers may bill you for any amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan does not have to pay the full amount for the core build up (D2950), the pulp cap (D3120), the crown (D2740), and the filling (D2332) provided on February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Oncotype DX Colon Cancer panel rendered on December
8, 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 the services were 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 pay for these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee has stage IIb moderately
differentiated adenocarcinoma of the ascending colon. The Oncotype DX colon cancer assay has not been
shown to impact management and outcomes in patients with colon cancer. Clinical validation in trials of
patients with stage II and III colon cancer have shown that recurrence scores are prognostic for recurrence but
are not predictive of benefit in regard to adjuvant therapy. The testing was not reasonable or medically
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the Oncotype DX Colon Cancer panel rendered on December 8, 2020.
The Plan references Local Coverage Article (LCA) A56199 in their determination; however, this LCA is not
binding for the state of California where the testing was performed and was not used in the Maximus
determination.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from December 11, 2020, through December 22, 2020.
You asked the Plan to pay for the inpatient admission. You say that the inpatient care was medically necessary. The Plan denied your request. The Plan says services that could have been performed at an in-network facility.
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 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 an inpatient admission provided from December 11, 2020, through December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement/repair of a semi-electric hospital bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your
request. The Plan says the hospital bed is not owned, and rental has not been capped.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
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 bed. Our reviewer says that the
requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does
not clearly reveal that your condition has failed positioning of the bed in ways not feasible in an ordinary bed
or why positioning of the bed in other ways is not feasible. The documentation from the physician does not
state you need frequent or immediate changes in body position. The documentation does not reveal a need for
special attachments that cannot be fixed on an ordinary bed. There is no evidence that the prior rental bed limit
has been capped.
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 bed have not been met. Therefore, we decided that the Plan does not have to
pre-approve replacement/repair of a semi-electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on November 17, 2020.
You asked the Plan to pay for the laboratory services. You say that the patient is prescribed narcotic medication and drug testing is needed to monitor possible abuse. You say that most in-network providers cannot perform such complex drug testing and the claim should be reprocessed per the Plan benefits. The Plan denied your request. The Plan says care must be received from a 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81291, 81401, 81403, 81404, 81405, 81406) provided September 9, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 81291, 81401, 81403, 81404, 81405, 81406 is not supported in the medical record. Specifically, the claim shows a place of service (81, laboratory) that differs from the place of service detailed in the records (11, office setting). 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 lab services (81291, 81401, 81403, 81404, 81405, 81406) provided September 9, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for neurology services (CPT 95909, CPT 95886) provided to the enrollee on October 6, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that the denied codes are not supported in the medical records submitted.
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 the denied codes is: CPT 95886:
complete needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; for five or more muscles studied, innervated by three ormore nerves or four or more spinal levels (listed separately in addition to code for primary procedure) CPT 95909: nerve condition studies, 5-6 studies 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 services at issue in this case were supported by the medical records. Our coding reviewer found the technical report clearly documents the CPT codes reported. Therefore, these services should be covered. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for neurology services (CPT 95909, CPT 95886) provided to the enrollee on October 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing provided on December 7, 2020.
You asked the Plan to pay for the testing services. You say that the testing provides a more accurate prediction of the enrollee's response to medications. The Plan denied your request. The Plan says the testing is not covered by Medicare.
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. There is insufficient evidence to support widespread use of combinatorial pharmacogenetic decision support tools at this point in time. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight testing provided on December 7, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on January 18, 2021 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy. You say that you would like this claim paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on January 18, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services provided to the enrollee from September 4, 2020, to September 30, 2020.
You asked the Plan to waive the coinsurance. The Plan denied your request. The Plan says the enrollee is responsible for the cost share.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for services provided in an outpatient hospital facility. Review of the file shows that the enrollee was provided outpatient services from September 4, 2020, to September 30, 2020. The enrollee has been asked to pay a 20% coinsurance for the services. The services fall within the outpatient services benefit category. This means that the enrollee has been asked to pay the correct
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the outpatient hospital services provided to the enrollee from September 4, 2020, to September 30, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom shoes and foot inserts.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve custom shoes and foot inserts.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 the services provided by an out-of-network provider on January 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept (A0432) provided on January 17, 2021.
You asked the Plan to pay for the transportation service. You say that you were transported from hospital to hospital. You say that you feel this should be covered. You also say that you cut your leg and needed help. The Plan denied your request. The Plan says the paramedic intercept service was not rendered in a rural area or rural New York. The Plan also says that the paramedic intercept is not covered.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept (A0432) provided on January 17, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Androgel.
You asked the Plan to pre-approve Androgel. You say that the enrollee is currently on this medication to maintain a safe testosterone level. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Androgel.
Benefits for Androgel may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 you had neck surgery and are in need or rehabilitation for recovery. The Plan denied your request. The Plan says that you do not need an intensive program with a team of health care professionals and doctors that specialize in complex medical needs as well as rehab.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. You
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.