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

We decided that the Plan does not have to pay for the insulin provided on August 24, 2020, and August 25, 2020.
You asked the Plan to pay for the insulin. You say that the insulin was not self-administered. You also say that hospitals do not permit any self-administered drugs during any hospital stay. The Plan denied your request. The Plan says the medications in question are classified as self-administered drugs of which none are covered under Medicare Part B.
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 pay for the insulin provided on August 24, 2020, and August 25, 2020.
Benefits for the insulin 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 12, 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 Medicare says tests with no relation to a diagnosis for the health of the patient are not a 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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the record indicates that the enrollee had an elevated prostate specific antigen, likely due to a urinary tract infection and benign prostatic hypertrophy. The record indicates that the treating urologist requested in be repeated in three months which coincided with this test. The medical record provided does not indicate any evidence of thyroid disease. The enrollee had a normal TSH on August 2016. This test is not recommended. 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 laboratory services provided to the enrollee on October 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the you have a history of low back pain that has not been controlled on hydrocodone, but the timeframe for which this medication has been taken is not documented. Furthermore, there is no documentation of trial and failure of other conservative treatments, such as physical therapy. There are no alarming signs or symptoms that would make an MRI of the spine urgent at this time. Therefore, an MRI of the lumbar spine is 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urine capacity measurement provided on October 22, 2020.
You asked the Plan to waive the copayment for the urine capacity measurement. You say that you've had this test done every visit and never had to pay. The Plan denied your request. The Plan says the copayment 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 $10 copayment for all other Medicare-covered diagnostic procedures and tests. You have been asked to pay $9.33, which is less than the standard $10 copayment for the urine capacity measurement. The urine capacity measurement 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 copayment for the urine capacity measurement provided on October 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 15, 2020.

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 procedure codes 63081, 63082, and 22854 are 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 63081 is vertebral corpectomy (vertebral body resection),
partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single
segment. The definition of code 63082 is vertebral corpectomy (vertebral body resection), partial or complete,
anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment
(List separately in addition to code for primary procedure). The definition of code 22854 is insertion of
intervertebral biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for
device anchoring (e.g., screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body
resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List
separately in addition to code for primary procedure).

We find that CPT codes 63081, 63082, and 22854 are not supported in the medical record. Specifically, the
operative report does not contain documentation of a partial or complete vertebral corpectomy to support code
63081. Given that the primary procedure code 63081 is not supported, add-on codes 63082 and 22854 are also
not supported. 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 surgical services rendered on
January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on October 9, 2020.
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 for date of service October 9, 2020. We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on October 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on September 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 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 to the enrollee by an out-of-network provider on September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the detailed and extensive oral evaluation provided on November 24, 2020.
You asked the Plan to pay for the detailed and extensive oral evaluation. You say that you were not aware that this provider had opted out of Medicare. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective April 1, 2014, to April 1, 2022. The Plan also says that charges incurred by Medicare opt out providers will not be reimbursed.
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 detailed and extensive oral evaluation provided on November 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (HCPCS G0482) services provided to the enrollee on August 27, 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 the records do not support the services 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. We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing (HCPCS G0482) services provided to the enrollee on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on September 29, 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 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 to the enrollee by an out-of-network provider on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar decompression procedure.

You asked the Plan to pre-approve the requested services. You say that this is a medically necessary procedure the enrollee needs. The Plan denied your request. The Plan says the enrollee is not in a clinical trial.

The Plan must follow Medicare rules. Medicare rules say that lumbar decompression for spinal stenosis is only covered under certain medical indication. 

We looked at the file and Medicare rules. The records in the case file do not indicate the enrollee is in an approved clinical study. 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 pre-approve a lumbar decompression procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0481) provided July 13, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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. We find that CPT code 80307, G0481 is not supported in the medical record. Specifically, the place of service on the claim (81, laboratory) does not match the place of service shown in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307, G0481) provided July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee 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 to the enrollee by an out-of-network provider on December 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device (E0651) and segmental pneumatic appliance (E0667) provided October 2, 2020.
You asked the Plan to pay for intermittent limb compression device and appliance. You say that you are attaching medical records for claim review. The Plan denied your request. The Plan says the documentation submitted does not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with
venous stasis ulcers. 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 intermittent limb compression device and appliance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the requirements as no lymphedema is documented in the examination of the enrollee or in the assessment of the enrollee. Nothing in the medical records provided indicates a need for a pneumatic compression 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 intermittent limb compression device and appliance have not been met. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device (E0651) and segmental pneumatic appliance (E0667) provided October 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 13, 2020 by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the service was provided with no adequate time frame to obtain authorization for the service. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.

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 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 subsequent nursing facility care provided on May 13, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a lightweight manual wheelchair provided on January 22, 2021.

You asked the Plan to pay for lightweight manual wheelchair. You say that the enrollee was unable to stand or
walk so this wheelchair would be useful for her. The Plan denied your request. The Plan says that the denial of
payment for this item is correct, because this wheelchair was not medically necessary and did not meet
coverage criteria.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.

This wheelchair was provided by an in-network provider. The file does not show that the plan provided notice
that lightweight manual wheelchair would not be covered. Under Medicare rules, this means lightweight
manual wheelchair is considered approved by the plan. Therefore, we decided that the Plan has to pay for a
lightweight manual wheelchair provided on January 22, 2021.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided November 19, 2020 to November 22, 2020.
You asked the Plan to pay for the skilled nursing facility services. You say that the services were medically necessary. The Plan denied your request. The Plan says a valid diagnosis code was not 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. We find that the skilled nursing facility services are not supported in the medical record. Specifically, the diagnosis code billed indicates this is an initial encounter. The records show the services were considered subsequent care. Based on this information, we decided that Medicare rules for coverage of the skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services provided November 19, 2020 to November 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis provided on October 1,
2020.

You asked the Plan to pay for orthotic item. You say that you have submitted all documents necessary to make
a determination of medical necessity for the item rendered. The Plan denied your request. The Plan says the
denial of payment for this item is correct, because the enrollee did not receive a video or telephonic visit from
the ordering physician and there are no claims on file from the ordering physician from 2019 to the present.

The Plan must follow Medicare rules. Medicare rules say that a face-to-face encounter is required within the 6
months prior to prescribing an item.

We looked at the file and Medicare rules. The documentation does not include a face-to-face encounter within
the 6 months prior to this item being prescribed, and the records submitted do not show that this order was
based on an approved use of telehealth examination for the purposes of ordering DMEPOS items. Based on this
information, we decided that Medicare rules for coverage of orthotic item have not been met. Therefore, we
decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis provided on October 1,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 27, 2020.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on July 27, 2020.