Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for an oncology colorectal screening (81528) rendered on April 20, 2021.  You asked the Plan to pay for an oncology colorectal screening. You say that your in-network physician ordered the colorectal cancer screening kit for you. You also believe that it should not matter where you fulfill the test requirements. The Plan denied your request. The Plan says that your medical group pays for routine non-emergency testing such as this service. The Plan only pays for hospital care and urgent medical care outside of your group's area. The Plan also says that this claim should have been sent directly to your medical group.  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.  You were referred for an oncology colorectal screening by a contract provider. The file does not show that the Plan provided notice that an oncology colorectal screening would not be covered. Under Medicare rules, this means an oncology colorectal screening is considered approved by the Plan. Therefore, we decided that the Plan has to pay for an oncology colorectal screening (81528) rendered on April 20, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-lab sleep study.

You asked the Plan to pre-approve an in-lab sleep study. You say that the medical records demonstrate that the requested sleep study is medically necessary. The Plan denied your request. The Plan says clinical documentation provided did not support a need for the requested sleep study.

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 an in-lab sleep study. Our reviewer says that an in-lab sleep study is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has asthma and obstructive sleep apnea (OSA.) A sleep study was requested. The provided documentation described the enrollee having disruptive snoring, witnessed apnea events, non-restorative sleep, disturbed or restless sleep, and excessive daytime sleepiness suggestive of possible sleep apnea. She reported claustrophobia with her F-20 full interface unit on positive airway pressure (PAP) but is feeling well otherwise after using it each night. Although consideration for switching out the device is reasonable, repeat sleep study is not supported as there was no other comorbidities requiring supervised sleep study in-house.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an in-lab sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve an in-lab sleep study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair.  You asked the Plan to pre-approve a power wheelchair. You say that the item is 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 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 a power wheelchair. Our reviewer says that the item is not medically necessary. Our physician reviewer found you do not have a personal mobility deficit that significantly impairs participation in mobility-related activities of daily living (MRADLs) in the home. You are noted to be independent in all activities of daily living (ADLs) and under exercise on the progress notes it states daily exercise. The documentation is not clear why you are unable to use a cane, walker, or manual wheelchair.  While you may be able to safely use the power mobility device the documentation does not support that this requested power wheelchair will significantly improve your ability to participate in MRADLs in the home. Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.3(B) criteria have not been met for the requested power wheelchair.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on June 22, 2021.

You asked the Plan to pay for the services provided. You say that the reports justify medical necessity. The Plan denied your request. The Plan says the billed codes cannot be verified.

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 49203 is excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less. We find that CPT code 49203 is not supported in the medical record. Specifically, the services billed are not described in the records provided. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.

In this case, the CPT Code Manual definition of code 49320-59 is Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure). The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on June 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from August 8, 2021, to August 9, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you went to the hospital feeling very bad. You say that you did not question the medication that you were given. You also say that you had no control over it. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not 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 self-administered drugs provided in an outpatient setting from August 8, 2021, to August 9, 2021.   Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an x-ray of the hand (73130) rendered on June 25, 2021.  You asked the Plan to waive the deductible for an x-ray of the hand. You say that the deductible was paid a long time ago and you would like us to look into that. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that that there is a $750 deductible that applies to the items and services specifically listed in the Plan contract.   You have been asked to pay $44.68 for an x-ray of the hand. X-rays of the hand fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible, which applies to Outpatient Diagnostic Tests and Therapeutic Services and Supplies. 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 that had not been met at the time the x-ray of the hand was rendered on June 25, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an x-ray of the hand (73130) rendered on June 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on June 1, 2021.  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 14301, 14302, and 15101 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 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 14302 is adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). The definition of code 15101 is split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure).  We find that CPT codes 14301, 14302, and 15101 are not supported in the medical record. Specifically, there is no documentation of an adjacent tissue transfer or rearrangement area, defect 30.1 sq cm to 60.0 sq cm, to support code 14301. Given that the primary procedure code 14301 is not supported, add-on code 14302 is also not supported. There is no documentation of a split-thickness autograft of the trunk, arms, or legs, each additional 100 sq cm each, to support code 15101. 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 June 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on February 16, 2021.  You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on February 1, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on February 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Myopro Motion G Orthotic device.  You asked the Plan to pre-approve Myopro Motion G Orthotic device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.  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 Myopro Motion G Orthotic device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in enrollees who have had a stroke. The MyoPro is not in widespread use based on scientific evidence.   There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Myopro Motion G Orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve Myopro Motion G Orthotic device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87500, 87150, 87640, 87481) provided on March 31, 2021.

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 out-of-network services were not emergent or pre-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 service 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 lab services (87500, 87150, 87640, 87481) provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99326) provided on June 23, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that you are submitting the claim with medical records that substantiate the medical necessity of the service performed. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 domiciliary or rest home visit (99326) provided on June 23, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the amalgam (D2150) provided on June 14, 2021.  You asked the Plan to pay for the dental service. You say that you have been going to this dentist most of your life. You also say that you think it is wrong that this bill is not covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services received out of network are not covered. The Plan also says you did not contact them prior to the date of service to verify provider's eligibility.  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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the amalgam (D2150) provided on June 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee has not had a change in function that needs daily skilled therapy services. The Plan says that no daily skilled nursing needs are noted.  

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and was to complete a course of IV antibiotics. The enrollee had stable vital signs. The enrollee was dependent at baseline with functional mobility and activities of daily living. There are no identifiable skilled therapy service needs. There are identifiable skilled nursing service needs but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the spine you had on June 8, 2021.  You asked the Plan to waive the copayment for the MRI. You say that when you had this service, the front desk told you that you only owed $21.39. The Plan denied your request. The Plan says you were charged this copayment 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 $125 copayment for radiological diagnostic services.      You have been asked to pay a $125 copayment for the MRI. The MRI falls within the radiological diagnostic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the spine you had on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injection services.

You asked the Plan to pre-approve facet joint injection services. You say that the medical records provided support the need for the injection services being requested. The Plan denied your request. The Plan says the requested injection services are not medically necessary because the enrollee has documented efficacy of less than 80% from the initial diagnostic facet joint block.

The Plan follows Medicare rules. Medicare rules say that, after the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used). 

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 facet joint injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there was not a consistent positive response of at least 80% relief of primary pain after the diagnostic facet joint procedure. The review has determined that it is not medically necessary or reasonable for the enrollee to have the requested 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 facet joint injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the semi-electric hospital bed (E0294) purchased April 7, 2021.  You asked the Plan to pay for the hospital bed. You say that you are requesting reconsideration of the denial as the bed is essential for your chronic back pain. This bed has given you the ability to sleep which the other medical care did not provide. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the semi-electric hospital bed (E0294) purchased April 7, 2021.