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

We decided that the Plan does not have to pre-approve a MyoPro 2 Motion-G orthotic device.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested MyoPro device is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. The services are considered experimental in nature and not 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 pre-approve a MyoPro 2 Motion-G orthotic device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Coflex device (22867).

You asked the Plan to pre-approve the insertion of a Coflex device. You say that there are several benefits to the Coflex including shorter operation time and faster recovery. 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 a Coflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Coflex device is experimental. More research is needed to show it is safe and effective. 

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 a Coflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Coflex device (22867).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile x-ray services rendered on September 16, 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 are not separately payable.

The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. 

We looked at the file and Medicare rules. Billed procedure codes R0070 (transportation of portable x-ray equipment) and Q0092 (set-up of portable x-ray equipment) have a PC/TC indicator of 3 and no separate professional component payment. 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 mobile x-ray services rendered on September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for transition lenses with anti-reflective coating provided on November 3, 2020.

You asked the Plan to pay for the transition lenses with anti-reflective coating. The Plan denied your request. The Plan says these upgraded materials are specifically excluded under the vision coverage and will not be covered, as stated in the Plan's Evidence of Coverage.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. The file shows that the Plan's vision benefit for eyeglasses after cataract surgery does not cover any upgrades including, but not limited to, deluxe frames, tinting, progressive lenses or anti-reflective coating. Therefore, we decided that the Plan does not have to pay for transition lenses with anti-reflective coating provided on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services (CPT code 99443) provided to the enrollee on December 4, 2020.

You asked the Plan to pay for the telehealth services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.

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 the telehealth services have not been met. Review of the records show the claim was improperly billed, as the enrollee's home address as the facility service location. An enrollee's home address is not an eligible originating site when billing telehealth services. Therefore, we decided that the Plan does not have to pay for telehealth services (CPT code 99443) provided to the enrollee on December 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for testing services (CPT 93286) provided to the enrollee on March 12, 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 this was denied because only the incidental service was reported, per Medicare guidelines.

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 93286 is "Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with physician analysis, review and report." 

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 not supported by the medical records. Our physician reviewer found in this case, the provided documentation does not indicate that a surgery, procedure or test was performed along with the requested service. The elements of the CPT code are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for testing services (CPT 93286) provided to the enrollee on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 20, 2020, by an OON
provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
You say that the provider is not responsible for requesting authorization. The Plan denied your request. The
Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not
refer 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 physician services provided on January 20, 2020,
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483 and 80307) provided on July 21, 2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the submitted claim was billed with a laboratory place of service code while the record indicates the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483 and 80307) provided on July 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient LTACH for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not
require transfer to the LTACH.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that in this case, the enrollee is on hg flow oxygen and is still tachypneic and
tachycardic. The enrollee is receiving acute care services. Acute care services have not been denied. The record
does not indicate that the enrollee requires services that the LTACH can provide that the enrollee is not able to
receive at the current facility.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to an inpatient LTACH for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee is currently in a short-term
acute care hospital, and LTACH is the appropriate level of care for continued ventilator weaning. The Plan
denied your request. The Plan says the denial of authorization for LTACH service is correct.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are
no services the enrollee requires at the LTACH that are not available at the health care setting offered by the
Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis
and condition of the enrollee at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services and does not have to waive the coinsurance for a Medicare Part B drug provided on January 15, 2021.

You asked the Plan to waive the copayment for specialist services and to waive the coinsurance for a Medicare Part B drug. You say that you already paid the copayment and disagree with the additional charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan says that you must pay a $45 copayment for specialist services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 

You received specialist services on January 15, 2021. Therefore, you are responsible to pay the $45 copayment. 

You received a Medicare Part B drug on January 15, 2021. The total allowed amount is $1.20 and 20% of that is $0.12. 

The total amount you owe is: $45.12. 

You have been asked to pay the total amount of $45.12 for specialist services and a Medicare Part B drug. Specialist services fall within the physician/practitioner services, including doctor's office visits benefit category. A Medicare Part B drug falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for specialist services and does not have to waive the coinsurance for a Medicare Part B drug provided on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet joint injection.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested procedure is supported for predominantly axial pain that is not associated
with radiculopathy.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there are other pain generators present, and therefore the criteria are not met. You have a T-11
vertebral body fracture which the physician has not addressed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a facet joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on December 18, 2019.

You asked the Plan to pay for the topical application of fluoride varnish. You say that you were not made aware that this service was not covered. The Plan denied your request. The Plan says topical application of fluoride varnish is not listed as a covered service.

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 topical application of fluoride varnish (D1206) provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on December 1, 2020.

You asked the Plan to waive the copayment for the eye exam. The Plan denied your request. The Plan says there is a $30 office visit copay per the Plan's benefits for a diagnostic eye exam.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 copayment for Vision Care, for exams to diagnose and treat diseases and conditions of the eye. 

You have been asked to pay $30 copayment for the eye exam. The eye exam falls within the Vision Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an eye exam provided on December 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95885), nerve conduction studies (95908), and neuromuscular junction testing (95937) provided on October 1, 2020.

You asked the Plan to pay for needle electromyography, nerve conduction studies, and neuromuscular junction testing. You say that these procedures are documented. The Plan denied your request. The Plan says these codes 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 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). The definition of 95908 is nerve conduction studies; 3-4 studies, and the definition of 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.

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 needle electromyography, nerve conduction studies, and neuromuscular junction testing. Our reviewer says that these codes are not supported. Our physician reviewer found the medical records provided do not document that a limited needle electromyography with nerve conduction was performed. The medical records document that pedicle screw stimulations were performed which are not baseline nerve conduction studies, therefore 95885 cannot be verified. The medical records provided do not document that a nerve conduction study of 3-4 studies was performed. The medical records document that pedicle screw stimulation was performed which are not baseline nerve conduction studies and do not meet the definition of CPT code 95908. Finally, the medical records submitted document Train of Four testing, which does not meet the coding definition of CPT 95937, therefore, this service cannot be verified.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography, nerve conduction studies, and neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95885), nerve conduction studies (95908), and neuromuscular junction testing (95937) provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for vision services provided on January 20, 2021.

You asked the Plan to reimburse you for the vision services. The Plan denied your request. The Plan says the Plan has paid the claim correctly. There is no coverage for a contact lens fitting/evaluation.

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. 

We looked at the file and the Plan's rules. The file shows that the Plan has paid the correct allowance toward the vision benefit. The Plan does not provided coverage for a contact lens fitting/evaluation. Therefore, we decided that the Plan does not have to reimburse you an additional amount for vision services provided on January 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says this is not reasonable and necessary according to Medicare guidelines.

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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to be functioning at/near his baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.