Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 19, 2020.

You asked the Plan to pay for the limited oral evaluation. You say that you would like this claim reprocessed and approved for payment for medical necessity. The Plan denied your request. The Plan says this service 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient rehabilitation services provided on July 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the inpatient rehabilitation services. You say that there was not time to submit a prior authorization. The Plan denied your request. The Plan says they found no exception to approve these services rendered 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 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 the inpatient rehabilitation services provided on July 24, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0328, A0429 and A0425) provided on December 14, 2019.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because this service was reported correctly. The Plan denied your request. The Plan says two or more diagnosis codes associated to it are mismatched per the ICD-10-CM Official Guidelines for Coding and Reporting.
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Specifically, this claim was billed with diagnosis codes R22.41 and R22.42 which indicate swelling of the left and right limbs. There is a more appropriate bilateral diagnosis code that should be used. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0328, A0429 and A0425) provided on December 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing for the enrollee.

You asked the Plan to pre-approve the testing. You say that the enrollee meets the established criteria for this request. The Plan denied your request. The Plan says Medicare does not cover genetic testing for familial cancer based on family history alone, no matter how strong the family history.

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 testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have a family history of colon cancer and a personal history of colonic polyps. As such, monitoring and screening for signs and symptoms related to colorectal cancer is warranted. Genetic testing may note another risk factor for colon cancer in this enrollee, but would not be diagnostic of cancer and would not alter the already established need for monitoring and screening. As such, the requested genetic testing is not medically necessary or reasonable. 

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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics received on July 31, 2020.
You asked the Plan to pay for foot orthotics. You say that the customer service representative spoke with the store manager and approved the services. The Plan denied your request. The Plan says the limits have been exceeded.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan has a supplemental benefit for foot orthotics, in which one pair is covered per year. The records show that therapeutic shoes and inserts were purchased previously on April 13, 2020. Although orthotics may be appropriate for you, only one pair is covered per year. Therefore, we decided that the Plan does not have to pay for foot orthotics received on July 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 1, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the orthosis is not supported in the medical records received.
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 lumbar-sacral orthosis (L0650). Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found the enrollee's chief complaint was chronic pain located in the lower back. The available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 10, 2019 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you rely on the hospital to obtain prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the rendering physician is out-of-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 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 September 10, 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 an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an acute inpatient rehabilitation facility admission.

The Plan must follow Medicare rules. The rules say that an 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 that you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3-level prosthesis 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 the requested microprocessor knee exceeds the enrollee's needs and cannot be covered.

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 the documentation does not demonstrate sufficient need for K3 level prosthesis. The physician and therapist notes do not indicate why a mechanical K3 knee would not be appropriate for the 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a K3-level prosthesis for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral formula.
You asked the Plan to pre-approve enteral formula. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that enteral therapy may be given by nasogastric, jejunostomy, or gastrostomy tubes and can be provided safely and effectively in the home by nonprofessional persons who have undergone special training. 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 enteral formula. Our reviewer says that the services are not medically necessary. Our physician reviewer found your provider did not confirm that you have a nasogastric, jejunostomy, or gastrostomy tube for administration. The review has determined that you do not meet the coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of enteral formula have not been met. Therefore, we decided that the Plan does not have to pre-approve enteral formula.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for HCPCS codes E0607, A4256, A4253, A4258 and A4259 billed for date of service June 19, 2020.

You asked the Plan to pay for the HCPCS codes E0607, A4256, A4253, A4258 and A4259.. You say that the medical records provided support the services in dispute. The Plan denied your request. The Plan says the billed services were not supported.

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 proof of delivery for the supplies provided in this case. The delivery slip that was provided is not itemized and does not show sufficient evidence that the specific items in dispute were delivered to the enrollee. 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 HCPCS codes E0607, A4256, A4253, A4258 and A4259 billed for date of service June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on September 22, 2020.
You asked the Plan to pay for the dental service. You say that your cleanings and x-rays have been covered in the past. You say that you were not advised that this was not covered throughout the course of your normal visit. You say that you do not know how you are supposed to determine what out of pocket costs are if the provider is free to add additional things that are not covered without telling you. The Plan denied your request. The Plan says periapical x-ray 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 periapical x-ray (D0220) provided on September 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new group 3 power wheelchair with multiple power options 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 the enrollee has a wheelchair that is less than five years old.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 medically reasonable or necessary. Our physician reviewer found the documentation does not support that the enrollee's current wheelchair requires replacement and is worn beyond repair. The documentation does not support that need for the requested Group 3 power wheelchair with multiple power options. The documentation does not reveal that the enrollee is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift. There is no evidence of intermittent catheterization for bladder management on the treating medical provider progress notes, or evidence of objective increased tone or spasticity on a physical exam on the treating medical provider progress notes. The E2311, E2377 Expandable Controller and E2313 Expandable Controller Harness are not medically necessary per Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function are sufficient to control any power options through their own switches. E2300 (Seat Elevator) does not serve a primary medical purpose and is therefore 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a new group 3 power wheelchair with multiple power options for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says the clinical information does not describe the results of a biopsy of the prostate.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
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 scan. Our reviewer says that the
requested scan is not medically reasonable and necessary. Our physician reviewer found this scan will not rule
out prostate cancer. Biopsy should be done as clinically indicated. MRI can be done to aid the biopsy.
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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve CT scan of the abdomen and pelvis for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laboratory tests provided on July 7, 2020, and July 20, 2020.
You asked the Plan to waive the copayments for laboratory tests. You say that you disagree with the charges because you have not had to pay for labs in the past. 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 $15 copayment for lab services. You received laboratory tests on July 7, 2020, at an outpatient hospital facility. Therefore, you are responsible to pay the $15 copayment. You received laboratory tests on July 20, 2020, at an outpatient hospital facility. Therefore, you are responsible to pay the allowed amount of $4.76, which is less than the $15 copayment. The total amount you owe is: $19.76. You have been asked to pay the total copayment amount of $19.76 for laboratory tests. Laboratory tests fall 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 copayments for laboratory tests provided on July 7, 2020, and July 20, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for allergy testing provided on June 15, 2020.
You asked the Plan to pay for allergy testing. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not include complete documentation of allergy testing for units billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95017 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify number of tests. The CPT Code Manual definition of code 95018 is Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests. We find that CPT code 95017, 95018 is not supported in the medical record. Specifically, there is no test interpretation or report specifying the number of tests. Based on this information, we decided that Medicare rules for coverage of allergy testing have not been met. Therefore, we decided that the Plan does not have to pay for allergy testing provided on June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown on tooth #18 for the enrollee.

You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your request. The Plan says there is a poor long-term prognosis for the tooth.

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 crown. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided x-ray shows mid-endodontic treatment with some distal bone loss and large distal are of prior decay. It does appear that a distal margin is available to be placed on #18 due to the loss of 15% bone support which exposed sufficient structure for tooth preparation despite the deep prior decay. The endodontic fill appears to be adequate, and tooth appears restorable. There is no supplied x-ray of the opposing teeth or an indication that there is, or will be, a lower partial denture that this tooth would be acting as an abutment for. The requirements under the plan state that review of x-rays of the opposing arch is a requirement for coverage. Although the prognosis of #18 with crown placement would be good, there is need to supply x-rays of the opposing teeth before there is consideration of the request for the crown on #18. 

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 crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #18 for the enrollee.