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

We decided that the Plan does not have to pre-approve a knee orthosis (item code L1851).

You asked the Plan to pre-approve knee orthosis. You say that your husband is going to get surgery, and without this brace you cannot walk to take care of him while he recovers. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because there is no clinical evidence of instability in the joint and you are able to walk without a limp, gait abnormality, or assistive device.

The Plan follows Medicare rules. Medicare rules state that knee orthoses may be covered under certain clinical conditions. 

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 knee orthosis. Our reviewer says that you do not meet the Medicare criteria for the requested knee orthosis. Our physician reviewer found there is no instability or severe knee degenerative joint disease documented. A knee brace is not needed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (item code L1851).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960) provided December 9, 2020.
You asked the Plan to pay for the orthosis. You say that these records proved the necessity for medical treatment and wearing a shoulder and back brace. The Plan denied your request. The Plan says the DME supplier conducts unsolicited outreach telephone calls to enrollee's. The documentation indicates services are not necessary for treatment of the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960) provided December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided on August 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for pain management services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for pain management services provided on August 26, 2020 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 provided by an out-of-network provider on July 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.
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 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 services provided by an out-of-network provider on July 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy sessions.
You asked the Plan to pre-approve additional physical therapy sessions. You say that you are beginning to make significant progress. The Plan denied your request. The Plan says rules for coverage have not been met because the requested services are not medically 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 additional physical therapy sessions.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of your condition. Our physician reviewer found that the requested therapy is generally accepted
as specific and effective therapy for your condition. However, the documentation is insufficient to demonstrate
that continued physical therapy with a professional therapist is required.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional physical therapy sessions have not been met. Therefore, we decided
that the Plan does not have to pre-approve 8 additional physical therapy sessions
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350 x4), a cone beam CT capture and interpretation (D0367), oral hygiene instructions (D1330), and topical application of fluoride (D1206) provided on March 10, 2021.

You asked the Plan to pay for 2D oral/facial photographic images, a cone beam CT capture and interpretation, oral hygiene instructions, and topical application of fluoride. You say that the services at issue were necessary. The Plan denied your request. The Plan says the services at issue are not covered 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.

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 2D oral/facial photographic images (D0350 x4), a cone beam CT capture and interpretation (D0367), oral hygiene instructions (D1330), and topical application of fluoride (D1206) provided on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 23, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 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 services provided by an out-of-network provider on December 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 10, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 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 services provided by an out-of-network provider on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on February 19, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 rest home visit provided on February 19, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for comprehensive oral evaluation (D0150), the panoramic x-ray (D0330), the limited oral evaluation (D0140), and the core build up (D2950) provided from October 21, 2019, to November 18, 2019.
You asked the Plan to reimburse you for the dental services. You say that you just found out that the enrollee had out of network coverage for dental services. You say that you were required to pay up front for the services, however they were not completed until January 2020. The Plan denied your request. The Plan says claims that have not been received within 12 months of 1 calendar year from the date when the services were rendered are not covered. The Plan also says that the claims in this case were received past the allowed 12-month time frame.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the dental services was not filed until February 17, 2021, and March 31, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to reimburse you for comprehensive oral evaluation (D0150), the panoramic x-ray (D0330), the limited oral evaluation (D0140), and the core build up (D2950) provided from October 21, 2019, to November 18, 2019.
Sincerely,
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus gene panel provided on June 24, 2020.

You asked the Plan to pay for the Tempus gene panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 Tempus gene panel is not supported in the medical record. Specifically, this service should be billed with code 81479. In addition, the appropriate DEX-Z code identifier should be entered adjacent in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the Tempus gene panel have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus gene panel provided on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on December 30, 2020.
You asked the Plan to pay for the therapeutic activities. You say that you disagree with the plan's denial. The Plan denied your request. The Plan says the services are not payable as 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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows that the services were performed by an occupational therapist assistant in a home health or hospice setting. This means there is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on February 12, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $50 copayment for services provided by a specialty care physician. You have been asked to pay a $50 copayment for the specialist office visit provided. 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 office visit (99214) provided on February 12, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS procedure.
You asked the Plan to pre-approve CardioMEMS. You say that CardioMEMS is medically reasonable and necessary for this enrollee. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because CardioMEMS is experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 CardioMEMS. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has severe heart failure with recurrent and recent hospitalizations for congestive heart failure. Management of his condition with standard medical therapy and relying on symptoms and signs has not been effective in keeping him with minimal symptoms and has resulted in acute hospitalizations. His medical therapy has been limited with hypotension, and he swings rapidly between under and over diuresis with concomitant volume depletion and renal insufficiency. He has had a variable response to diuretics which must be adjusted frequently. CardioMEMS monitoring in this situation can provide additional heart filling pressure data to better manage very complex diuretic and vasodilator regimens. Data from a trial along with longer term follow-up studies have shown a significant decrease in hospitalization and mortality with use of this device. There is also published expert opinion in the cardiology literature as to its appropriate use, Food & Drug Administration (FDA) approved indications, as well as reasonable patient selection criteria, all of this are met in this clinical instance. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS procedure.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiofrequency ablation to the sacroiliac joint (64625) provided November 20, 2020.

You asked the Plan to pay for outpatient surgery services. You say that CPT 64625 was denied as experimental and your office believe the denial is incorrect. The Plan denied your request. The Plan says the use of radiofrequency ablation for pain management related to sacroiliitis has not been shown to provide a clear long-term benefit over standard treatment for chronic sacroiliac joint pain.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of outpatient surgery services have not been met. Therefore, we decided that the Plan does not have to pay for radiofrequency ablation to the sacroiliac joint (64625) provided November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), retainer crown - porcelain/ceramic (D6740), and abutment supported porcelain/ceramic crown (D6058) provided April 6, 2021.

You asked the Plan to pay for core buildup, retainer crown, and abutment supported crown. You say that due to previous radiation treatment for cancer, these services should be processed under your medical benefits. The Plan denied your request. The Plan says these services are not covered under your dental benefits and the Plan is reviewing whether the services are eligible for medical coverage under a separate appeal.

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 core buildup, including any pins when required (D2950), retainer crown - porcelain/ceramic (D6740), and abutment supported porcelain/ceramic crown (D6058) provided April 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for PT and OT services provided from August 1, 2019, through
August 23, 2019.
You asked the Plan to pay for the PT and OT. You say that the services were medically necessary. The Plan
denied your request. The Plan says there is insufficient clinical documentation to support coverage.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents
to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the
PT and OT have not been met. Therefore, we decided that the Plan does not have to pay for PT and OT)
services provided from August 1, 2019, through August 23, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing
facility, a residential long term care facility, or home with home health.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for surgical treatment of a bowel obstruction. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.