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

We decided that the Plan does not have to pay for F1Heme testing.

You asked the Plan to pay for the F1Heme testing.. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says this testing was not billed correctly.

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 the F1Heme testing.. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is not enough clinical information provided to support molecular profiling with FoundationOne Heme.

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 F1Heme testing. have not been met. Therefore, we decided that the Plan does not have to pay for F1Heme testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a remote 30 day ECG (93229).

You asked the Plan to pre-approve a remote 30 day ECG (93229). You say that the requested remote 30 day ECG (93229) is medically necessary. The Plan denied your request. The Plan says the requested remote 30 day ECG (93229) is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a remote 30 day ECG (93229). Our reviewer says that the requested remote 30 day ECG (93229) is not medically necessary. Our physician reviewer found based on the records the enrollee has coronary disease and atypical chest pain with normal ventricular ejection fraction, no regional dysfunction, no provokable ischemia, no palpitations and no syncope. In this circumstance the identification of additional ventricular tachycardia on monitoring may change therapy but should be able to be adequately identified on Holter monitoring or auto-triggered off-line event monitoring. On line outpatient telemetry monitoring (MCOT) is not medically necessary since the procedure exceeds the enrollee's medical needs based on the records provided.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a remote 30 day ECG (93229) have not been met. Therefore, we decided that the Plan does not have to pre-approve a remote 30 day ECG (93229).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services.

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says this provider has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing accessories (L8619, L8624, L8615, L8616).

You asked the Plan to pay for the hearing accessories. You say that the services provided were medically
necessary. The Plan denied your request. The Plan says an itemized shipping/billing invoice was not included
that indicates the specific supplies or proof of delivery.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain a valid delivery service record. In this case, the delivery service record does not
appear to be linked to the supplier's delivery documents. The record shows that the Plan made several attempts
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to
pay for the hearing accessories (L8619, L8624, L8615, L8616).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not enrolled in Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the services
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two additional home physical therapy visits.

You asked the Plan to pre-approve home physical therapy visits.. You say that the two home physical therapy
visits are medically necessary. The Plan denied your request. The Plan says skilled physical therapy services
are not needed to restore or maintain function to prevent deterioration of the enrollee's condition. The Plan also
says that the enrollee and caregivers have been instructed in a home exercise program.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.

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 home physical therapy visits. Our
reviewer says that the two additional home physical therapy visits are not medically necessary. Our physician
reviewer found the documentation does not support that the enrollee requires skilled rehab services to provide
treatment that is medically necessary. The reviewer found that the enrollee does not require rehab services to
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a
maintenance program to maintain the enrollee's condition or prevent deterioration. The reviewer found that the
enrollee has been medically stable without any recent exacerbations of chronic medical problems or
hospitalizations. The reviewer also found that the enrollee has had adequate physical therapy sessions to
establish a home exercise program. Therefore, the reviewer found that the two additional therapy sessions are
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 home physical therapy visits. have not been met. Therefore, we decided that the
Plan does not have to pre-approve two additional home physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the denture.

You asked the Plan to pay for the denture. The Plan denied your request. The Plan says that the denture benefit has been exhausted.

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 has not provided documentation showing that an upper denture was provided and paid for in the past 5 years. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the denture.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction.

You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not a covered benefit.

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 during a routine exam performed by an EyeQuest Routine Vision Care Provider.

We looked at the file and the Plan's rules. The documentation does not show that the refraction was provided during a routine exam performed by an EyeQuest Routine Vision Care Provider. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.

You asked the Plan to pay for the SNF services. You say that the services provided to the enrollee are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee had returned to his prior baseline level of function. The Plan says that the enrollee was no longer making progress. The Plan also says that skilled nursing services were not necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the SNF services provided have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and x-rays.

You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit and x-rays.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot, plastic, silicone or equal, heel stabilizer (L3170) and
ankle foot orthosis (L1971).

You asked the Plan to pay for the foot, plastic, silicone or equal, heel stabilizer and ankle foot orthosis. You say
that these services were medically necessary. The Plan denied your request. The Plan says the services were not
supported by a physician exam.

The Plan follows Medicare rules. Medicare rules say that ankle-foot orthoses are covered for ambulatory
beneficiaries with weakness of deformity of the foot and ankle. Medicare rules also say that inserts and other
shoe modifications are covered if they are on a shoe that is an integral part of a covered brace.

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 foot, plastic, silicone or equal, heel
stabilizer and ankle foot orthosis. Our reviewer says that the services are not medically necessary. Our
physician reviewer found the medical records do not support that the patient has weakness or deformity of the
foot and ankle on an objective physical exam that and requires stabilization for medical reasons, and, has the
potential to benefit functionally from the ankle-foot orthosis.

We looked at this physician's review, the file, and Medicare rules. The file indicates that the foot, plastic,
silicone or equal, heel stabilizer is not being used as an integral part of a covered brace. Based on this
information, we decided that Medicare rules for coverage of the foot, plastic, silicone or equal, heel stabilizer
and ankle foot orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the
foot, plastic, silicone or equal, heel stabilizer (L3170) and ankle foot orthosis (L1971).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray.

You asked the Plan to pay for the X-ray. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 did not pre-approve the X-ray. 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
X-ray.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work.

You asked the Plan to waive the copayment for the laboratory work. You say that you should not have a copayment for laboratory work. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 clearly says that you must pay a $15 copayment for Medicare-covered laboratory services completed in an outpatient hospital.

You have been asked to pay a $15 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the laboratory services were provided by an outpatient hospital.

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 laboratory work.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system.

You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF system is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CardioMEMS HF system. Our reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMS HF system have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950), two retainer crowns (D6740),
and a pontic (D6245).

You asked the Plan to pre-approve the core build up for tooth #14, retainer crowns, and pontic. You say that
you need this work done. You say that tooth #7 has had a root canal and needs a crown so that it will not break.
You say that tooth #12 does have significant decay. You say that tooth #13 is missing because you had it pulled
this morning. You say that tooth #14 is broken. You also say that if you do not get it bridged or crowned then
that tooth will have to be pulled too. The Plan denied your request. The Plan says bridges are only covered for
anterior teeth. The Plan says that teeth 7 and 14 do not have significant enough breakdown due to decay or
trauma. The Plan also says that the requested services are not necessary.

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. The Plan covers the core build
up for tooth #14, retainer crowns, and pontic when the services are medically necessary and reasonable.

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 core build up for tooth #14, retainer
crowns, and pontic. Our reviewer says that the bridge is not medically necessary. Our physician reviewer found
the Plan criteria states that fixed bridgework is only allowable where there is one missing anterior tooth. The
reviewer found that in this instance, there is one missing posterior tooth, #13, that is to be replaced. The
reviewer found that under the Plan provisions, there would not be coverage for a posterior tooth that is being
replaced. Therefore, the reviewer found there is no necessity for the requested bridge.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the core build up for tooth #14, retainer crowns, and pontic have not been met.
Therefore, we decided that the Plan does not have to pre-approve core build up (D2950), two retainer crowns
(D6740), and a pontic (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement (D4355).

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.

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 services are not among those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. Full mouth debridement is not covered. Therefore, we decided that the Plan does not have to pay for the full mouth debridement (D4355).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.

You asked the Plan to pre-approve a semi-electric hospital bed. You say that the requested semi-electric hospital bed is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested semi-electric hospital bed.

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 a semi-electric hospital bed. Our reviewer says that the enrollee does not meet criteria for the requested semi-electric hospital bed. Our physician reviewer found a semi-electric hospital bed is not medically necessary per Medicare National Coverage Determinations Manual, Section 280.7(A) and 280.7(D). The documentation does not clearly reveal that the enrollee's 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 does not support a need for an immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.