Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on September 3, 2019 to September 27, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that it was unknown that authorization was required until denial was received. The Plan denied your request. The Plan says the services were not urgent, or 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 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 OON services. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on September 3, 2019 to September 27, 2019 by an out of network (OON) provider.
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 the requested IRF care is considered medically
reasonable and necessary The Plan denied your request. The Plan says the requested IRF care is not considered
medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's
current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may
benefit from additional multiple therapies, however the enrollee's functional level does not require or indicate
that this therapy must be in an IRF with an intensive level program.
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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 18, 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 the services are not separately payable.
The Plan must follow Medicare rules. The rules say that services furnished while an enrollee is inpatient must
be billed with the POS code 21 to trigger payment.
We looked at the file and Medicare rules. The file shows that the laboratory services were billed with POS code
81 for an independent laboratory; however, the enrollee was inpatient at the time the services were rendered.
These services must be billed with POS code 21. Therefore, we decided that the Plan does not have to pay for
the laboratory services rendered on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on March 19, 2019 to March 22, 2019. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not support that a face to face encounter occurred in the preceding six months of the written order/prescription. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on March 19, 2019 to March 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the stem cell injection you received on October 2, 2019.
You asked the Plan to pay for the services provided. You say that the stem cell injections have provided such
relief. The Plan denied your request. The Plan says the service 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. The rules say that the service at issue is non-covered. Therefore, we
decided that the Plan does not have to pay for the stem cell injection you received on October 2, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health physical and occupational therapy.
You asked the Plan to pre-approve the services. You say that these services are essential to enable the enrollee to continue living independently and safely. The Plan denied your request. The Plan says the individualized assessment of the enrollee's clinical condition must demonstrate that the specialized judgment, knowledge, and skills of a qualified physical therapist and occupational therapist are necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. Your functional level does not require ongoing skilled therapy services. You were instructed in and can transition to an independent home exercise program.
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 pre-approve continued home health physical and occupational therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic brachytherapy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is considered experimental and investigational for treatment of basal cell and
squamous cell cancers of the skin.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found radiation is a standard approach to the treatment of skin cancer, and is often preferred over surgery when
resection is likely to result in unacceptable morbidity or cosmesis. Many factors determine which of many
treatments are best suited for an individual patient- including histology (squamous cell or basal cell carcinoma),
size (T stage), depth, location, comorbidities. For this case, there are no compelling reasons offered for why
EBT would be needed over more standard approaches of radiation delivery. Recent papers in JAMA highlight
the aforementioned concerns about the use of electronic brachytherapy (which poses similar concerns as SRT)
(Linos E et al. A Sudden and Concerning Increase in the Use of Electronic Brachytherapy for Skin Cancer.
JAMA Dermatol. 2015 Jul;151(7):699-700 and Haffty et al. Radiation Oncologist Concerns About Increased
Electronic Brachytherapy Use for Skin Cancer. JAMA Dermatol. 2015 Sep;151(9):1036-7.).
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 pre-approve electronic brachytherapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the stem cell injection you received on October 2, 2019.
You asked the Plan to pay for the provided service. You say that your knees are no longer in pain. The Plan
denied your request. The Plan says the service 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. The rules say that the service at issue is non-covered. Therefore, we
decided that the Plan does not have to pay for the stem cell injection you received on October 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crown-porcelain/ceramic teeth 8-9, (D2740) provided January 2, 2020.
You asked the Plan to pay for the dental services. You say that you made it very clear to the provider to get in touch with the plan before any work was done. You said you would like your gap to be filled and the hygienist said you needed cleaning and bleaching. The Plan denied your request. The Plan says crowns for cosmetic reasons or for closing gaps are not covered.
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 health plan contract says that crowns for cosmetic reasons or for closing gaps are not covered. 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 crown-porcelain/ceramic teeth 8-9, (D2740) provided January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751), Core Buildup (D2950), and Porcelain
Pontic and Crown (D6241, D6751).
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The
Plan denied your request. The Plan says rules for coverage were not met.
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 crowns and
buildups when the services are medically necessary and reasonable. Porcelain crowns and pontics are not
covered benefits.
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 dental services. Our reviewer says
that the crown and core buildup are not medically necessary at this time. Our physician reviewer found the
crown and core buildup cannot be covered until the root canal has been performed. The provided x-rays are
limited and do not support the medical necessity of the requested procedures.
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 dental services have not been met. Therefore, we decided that the Plan does
not have to pre-approve a crown (D2751), Core Buildup (D2950), and Porcelain Pontic and Crown (D6241,
D6751).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing services provided to the enrollee on January 1, 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 remain 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 the denied codes is:
CPT 80307:
Drug test(s), presumptive, any number of drug classes, any numberof devices or procedures; by instrument
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA,IA, KIMS, RIA]),
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg,DART,
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation
whenperformed, per date of service.
HCPCS G0482:
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individualdrugs and
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to,
GC/MS(any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays
(e.g., IA, EIA, ELISA,EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope
or other universally recognized internal standards in all samples (e.g., to control for matrix effects,
interferences and variations in signal strength), and (3)method or drug-specific calibration and matrix-matched
quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or
quantitative, all sources, includes specimen validity testing, per day; 15-21 drugclass(es), including
metabolite(s) if performed."
We asked our coding 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 reviewers says that the
services at issue in this case were coded correctly. Our coding reviewer found the documentation submitted
does support CPT code 80307 and HCPCS G0482. An outside laboratory typically receives a signed physicians
order, but would not send verification that the patient is the signing physicians patient.
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
drug testing services provided to the enrollee on January 1, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP rental provided on November 4, 2019 by an out of
network provider.
You asked the Plan to pay for the CPAP rental. You say that the CPAP is required for a lifetime but you moved
and changed plans. The Plan denied your request. The Plan says the provider is not in network and you did not
request prior approval.
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 at issue in this appeal. The Plan did not pre-approve the item at issue. We
found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does
not have to pay for the CPAP rental provided on November 4, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic appliance for the enrollee.
You asked the Plan to pre-approve the appliance. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no failed four week trial with a model without calibrated pressure.
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 appliance. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found based on the medical records provided there is not documentation of a four week trial and
failure of the standard pump.
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 appliance have not been met. Therefore, we decided that the Plan does not
have to pre-approve a pneumatic appliance for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal irrigation for teeth 25-32, 9-16, 1-8, and 17-24
(D4921) provided on February 25, 2020.
You asked the Plan to pay for the dental services. You say that all claims were filed out of network several
times, incorrect coding and failure to telephone Medicare to confirm coverage for necessity. As a result you
were informed to pay out of pocket. The Plan denied your request. The Plan says this service is not covered
under the plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Services not listed on the
Description of Benefits is not covered by the plan.
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
periodontal irrigation for teeth 25-32, 9-16, 1-8, and 17-24 (D4921) provided on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP rental provided on August 4, 2019 by an out of network provider. 
 
You asked the Plan to pay for the CPAP rental. You say that the CPAP is required for a lifetime but you moved and changed plans. The Plan denied your request. The Plan says the provider is not in network and you did not request prior approval. 
 
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 at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the CPAP rental provided on August 4, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on
October 15, 2019.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment was applied correctly.
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 $350
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.
Review of the file shows that you received a cortisone injection at an outpatient hospital facility on October 15,
2019. You have been asked to pay a $350 copayment for these services. These services fall within the
Medicare-covered surgery or other services provided to you at an outpatient hospital 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 the outpatient hospital services rendered on October 15,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 6, 2019. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.   Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an open minimally invasive posterior fusion for C3-4,
C4-5, and C5-6.
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says the
posterior cervical fusion along with the anterior fusion to the same area in the neck does not provide any
additional benefit.
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 requested service. Our physician
reviewer found that the posterior surgery is not needed. The enrollee is approved for anterior surgery. There is
no need for the second posterior procedure.
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 requested service have not been met. Therefore, we decided that the Plan
does not have to pre-approve an open minimally invasive posterior fusion for C3-4, C4-5, and C5-6.