Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 97163, CPT 99350) provided on August
26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes do not
appropriately reflect the services provided.
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 97163 is "Physical therapy evaluation: high complexity,
requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities
that impact the plan of care; An examination of body systems using standardized tests and measures addressing
a total of 4 or more elements from any of the following: body structures and functions, activity limitations,
and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and
Clinical decision making of high complexity using standardized patient assessment instrument and/or
measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient
and/or family". The CPT Code Manual Definition of code 99350 is "Home visit for the evaluation and
management of an established patient, which requires at least 2 of these 3 key components: A comprehensive
interval history; A comprehensive examination; Medical decision making of moderate to high complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have
developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent
face-to-face with the patient and/or family".
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 use
of CPT codes 97163 and 99350 is not supported by the records provided. Our physician reviewer found that the
Physical Therapy Evaluation is signed by a PTA. Per CPT guidelines, Physical Therapy evaluations are
required to be performed by physician or other qualified healthcare provider.
A PTA is not considered a qualified healthcare provider. CPT code 99350 is a physician or qualified healthcare
professional reporting code. This code requires the physician or qualified healthcare professional to be present
in the home.
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 the services (CPT 97163, CPT 99350) provided on August 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on
January 26, 2019.
You asked the Plan to pay for the drug testing. You say that this is medically necessary testing which should be
paid. The Plan denied your request. The Plan says the documentation does not support that the correct POS
code was used.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a
treating provider.
In this case, no copy of a valid order form was included. The testing results were also not present in the file.
Without this documentation, we cannot confirm that there was intent by the physician to order this testing.
Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing
provided on January 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cardiac flow reserve test provided on
December 31, 2019.
You asked the Plan to waive the coinsurance for the cardiac flow reserve test. You say that the cost for this
service seems excessively high. 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 20%
coinsurance for Medicare-covered services.
You have been asked to pay $2,422.28 which is 20% of the allowed amount for the cardiac flow reserve test.
The allowed amount is $12,111.40. ($12,111.40 x 20% = $2,422.28). The cardiac flow reserve test falls within
the "Outpatient diagnostic tests and therapeutic services and supplies" 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 coinsurance for the cardiac flow reserve test provided on December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Decipher biopsy testing provided on January 31, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says prior
authorization was not provided for the service.
The Plan must follow Medicare rules. Medicare rules say that plan may require enrollees to obtain
authorization before receiving services.
We find that the testing at issue is not supported in the medical record. In this case, there were insufficient
records provided to show the results of this testing would be used to determine a specific diagnosis, or specific
treatment strategy, or that the services were medically necessary for the enrollee at the time of service. 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 Decipher biopsy testing provided on January 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2 motion orthotic device for the enrollee.
You asked the Plan to pre-approve this device. You say that this is medically necessary. The Plan denied your
request. The Plan says that the clinical value/effectiveness of this orthosis has not been established in the peer -
reviewed medical literature.
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 this device. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. At this time the
requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical
condition/function of hemiparesis after stroke than any available standard therapy. The requested device is not
reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a
malformed body member. Our physician reviewer found that the enrollee's condition does not meet criteria for
this device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this device have not been met. Therefore, we decided that the Plan does not
have to pre-approve a MyoPro 2 motion orthotic device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 29, 2019 by an out
of network (OON) provider.
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 rendered by an out-of-network provider without prior authorization.
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 has network providers
available who can provide 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 the medical services provided on March 29, 2019
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 97163) provided on August 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records indicate a physical therapy evaluation by a licensed physical therapist did not occur on the date of service.
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 97163 is "Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family". 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 use of CPT code 97163 is not supported by the records provided. Our physician reviewer found that CPT 97163 was performed by a Physical Therapy Assistant (PTA) on August 21, 2019. Per the code description, there is clinical decision making of high complexity, which does not fall within the scope of a Physical Therapy Assistant.
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 the services (CPT 97163) provided on August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a motion orthotic device.
You asked the Plan to pre-approve this device. You say that this is medically necessary. The Plan denied your
request. The Plan says that medical studies haven't proven that the device is helpful for treatment of your health
problem.
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 this device. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. At this time the
requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical
condition/function of hemiparesis after stroke than any available standard therapy. The requested device is not
reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a
malformed body member. Our physician reviewer found that your condition does not meet criteria for this
device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this device have not been met. Therefore, we decided that the Plan does not
have to pre-approve a motion orthotic device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 1, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 October 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that LTACH services will give the enrollee
the best opportunity for continued improvement and eventual discharge home. The Plan denied your request.
The Plan says that there are no required medical services identified that are available at the LTACH, that are
not available at the current healthcare setting.
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. The patient
is currently undergoing treatment at an acute care hospital following coronary bypass surgery. The enrollee was
intubated/ventilated perioperatively, but has since been extubated and is no longer on a ventilator. There is no
evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed
to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee
can remain at the current ACH until such time no acute services are required. The enrollee can then be
transferred/discharged to a lower level of care for any ongoing long term care needs. Our physician reviewer
found that the enrollee's condition does not meet Medicare criteria for LTACH services.
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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ketorolac, midazolam, ondansetron, Propofol, and
fentanyl billed for use during a hysteroscopy with biopsy on October 23, 2019.
You asked the Plan to pay for the billed drugs. You say that this should be paid in full. The Plan denied your
request. The Plan says the documentation does not include evidence of the billed amounts of these drugs.
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 the drug codes billed are not supported in the medical record. Specifically, although it is noted that
anesthesia was provided, there is no documentation of the actual drugs and amounts used to support the billing
of these codes. Based on this information, we decided that Medicare rules for coverage of the billed drugs have
not been met. Therefore, we decided that the Plan does not have to pay for the ketorolac, midazolam,
ondansetron, Propofol, and fentanyl billed for use during a hysteroscopy with biopsy on October 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec orally disintegrating tablets.
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee has tried other medications, but this is the only effective medication. The Plan denied your request. The Plan says the denial of authorization for these drugs is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Nurtec orally disintegrating tablets.
Benefits for self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home blood pressure monitor.
You asked the Plan to pre-approve a home blood pressure monitor. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested
item.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require
ABPM to confirm a diagnosis of hypertension.
The records do not show that this monitor is requested in the setting of home dialysis services, or that this
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.
Therefore, we decided that the Plan does not have to pre-approve a home blood pressure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on
January 8, 2020.
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the
charges because your primary care doctor was not available. 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 clearly says that you must pay a $45
copayment for urgently needed services.
You have been asked to pay a $45 copayment for urgently needed services. Urgently needed services falls
within the urgently needed services 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
urgently needed services provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on February 7, 2020 by a
provider not participating with Medicare.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the provider opted out of Medicare.
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 dental office opted out of Medicare September 29, 2015. The Medicare rules say that Medicare Advantage
Plans may not make payment directly or indirectly for Medicare covered services furnished to a Medicare
beneficiary by a physician or practitioner who has opted out of Medicare. 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. The Plan did not pre-approve the item/service at issue. We found no
exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the dental services provided on February 7, 2020
by a provider not participating with Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on February 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are
available 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 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 has network providers
available who can provide 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 medical services provided to you by an out-of-network provider on
February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 4, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan
requires utilization of network providers when possible and available and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
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
laboratory services. 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 laboratory services provided on February 4, 2019.