Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services you received from August 5, 2021, to September 23, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you were not aware that to receive out-of-network benefits that the provider had to accept Medicare. The Plan denied your request. The Plan says this provider has opted-out of Medicare and therefore these services cannot be paid.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services you received from August 5, 2021, to September 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system.
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF
system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF
system 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 a CardioMEMS HF system. Our
reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer
found the CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and
consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure
in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval
was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was
somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be
considered medically appropriate and necessary in this enrollee's clinical management.
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 CardioMEMS HF system have not been met. Therefore, we decided that the
Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on August 16, 2021.
You asked the Plan to pay for the therapeutic or diagnostic injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the medical necessity of the services billed.
The Plan must follow Medicare rules. Medicare rules say that the procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic or diagnostic injection have not been met. Specifically, the medical records submitted are not signed and do not include the pre and post percent pain relief achieved immediately post-injection. Therefore, we decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473 x 2) and therapeutic parenteral drug (D9610).
You asked the Plan to pre-approve the dental services. You say that you had all of your teeth pulled so that you could get dentures. You also say that you need to have your jaw bones ground down. The Plan denied your request. The Plan says removal of torus mandibularis is not listed as a covered service. The Plan says that therapeutic parenteral drug is not listed as a covered service either.
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 pre-approve removal of torus mandibularis (D7473 x 2) and therapeutic parenteral drug (D9610).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power lift recliner you purchased on May 5, 2021.

You asked the Plan to pay for the power lift recliner. You say that you would like this to be reconsidered because this is a big expense for you. The Plan denied your request. The Plan says you do not have a condition for which seat lifts are covered.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. Specifically, in order for a seat lift to be covered, you must have either severe arthritis of the hip or knee or a severe neuromuscular disease. According to your medical records, you do not have any of these conditions. Based on this information, we decided that Medicare rules for coverage of the power lift recliner have not been met. Therefore, we decided that the Plan does not have to pay for the power lift recliner you purchased on May 5, 2021.

Please note that it appears as though you may have also requested coverage of a walker. The Plan has not sent us a case file regarding that issue. If you wish to appeal for coverage of that item, please contact the Plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapies (procedure code 97140) and office visit
evaluations (99213) you received from a chiropractor from December 2, 2021, to December 13, 2021.
You asked the Plan to pay for the manual therapies and office visits. You say that you were under the
impression that these services were covered. The Plan denied your request. The Plan says it has covered the
manual manipulation of the spine services you received during these chiropractic visits. However, the Plan
states that these additional chiropractic services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for manual therapies (procedure code 97140) and office visit evaluations
(99213) you received from a chiropractor from December 2, 2021, to December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service July 19,
2021.
You asked the Plan to pay for procedure code 62320. You say that these services were billed correctly so they
should be paid. The Plan denied your request. The Plan says the medical records do not support payment for
this service.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain
documentation requirements must be met. The documentation must include a procedure report that clearly
documents the indications and the medical necessity for the blocks along with the pre and post percent pain
relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record
does not include a notation of the percent of pain relief achieved either before or after the injection. Therefore,
we decided that the Plan does not have to pay for procedure code 62320 billed for date of service July 19, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site
(D4266).
You asked the Plan to pre-approve guided tissue regeneration. You say that the enrollee needs this service. The
Plan denied your request. The Plan says this service is not covered under the enrollee's 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 pre-approve
guided tissue regeneration - resorbable barrier, per site (D4266).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 97016 billed for date of service May 3, 2021.

You asked the Plan to pay for procedure code 97016. You say that you have provided medical records to support payment of this code. The Plan denied your request. The Plan says you did not bill this code with a required modifier.

The Plan must follow Medicare rules. Medicare rules say that procedure code 97016 requires a GN, GO, or GP modifier. You did not bill code 97016 with any modifier. Based on this information, we decided that Medicare rules for coverage of procedure code 97016 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 97016 billed for date of service May 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on September 20, 2021.
You asked the Plan to pay for the therapeutic or diagnostic injection. You say that you would like reconsideration based on the records . The Plan denied your request. The Plan says the documentation submitted does not support the medical necessity of the service billed.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have
been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic or diagnostic injection have not been met. Specifically, the documentation submitted does not include any medical records. There is insufficient information to determine if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on September 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on
October 11, 2021.
You asked the Plan to pay for the therapeutic or diagnostic injection. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation
submitted does not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must corroborate the
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the therapeutic or diagnostic injection have not been met. Specifically, the documentation
submitted does not include any medical records. There is insufficient information to determine if Medicare
criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the
therapeutic or diagnostic injection (62320) provided on October 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673 and E0675).
You asked the Plan to pay for a pneumatic compression device. You say that you would like reconsideration because this device is medically necessary and the standard of care. The Plan denied your request. The Plan says the member does not meet LCD criteria for coverage of this device.
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673 and E0675).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 36556 billed for date of service August 24,
2021.
You asked the Plan to pay for procedure code 36556. You say that this was an unrelated service to the surgery
that occurred on August 16, 2021. You said that you used the -79 modifier to indicate this. The Plan denied
your request. The Plan says this service occurred within the 90-day global surgery period, so no separate
payment can be made.
The Plan must follow Medicare rules. Medicare rules say that when a major surgery is performed, the global
surgery period is 90 days. Generally, return trips to the operating room during the postoperative period is
included in the global surgical package. However, if the return procedure is unrelated to the original surgery,
the provider should append modifier -79 to the claim.
In this case, the patient had major surgery on August 16, 2021. The patient returned to the operating room on
August 24, 2021 and received services represented by procedure code 36556. Although you claim that you
billed this with a -79 modifier to indicate that this was unrelated to the initial surgery, there is no -79 modifier
on the electronic claim you submitted. Without such a modifier, code 36556 is not separately payable outside
of the global surgical package. If you wish to submit a corrected claim, please contact the Plan directly.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of procedure code 36556 have not been met. Therefore, we decided that the Plan does not have to pay
for procedure code 36556 billed for date of service August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy services provided to the patient on June 2, 2021.
You asked the Plan to pay for the medical nutrition therapy services. You say that these services were medically necessary. The Plan denied your request. The Plan says these services are not covered due to the patient's diagnosis.
The Plan must follow Medicare rules. Medicare rules say that medical nutrition therapy is only covered for patients with renal disease or diabetes. The medical records in this case show that you provided medical nutrition therapy to a patient who does not have either of these conditions. Rather, these services were provided due to weight loss related to pancreatic cancer.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical nutrition therapy services have not been met. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy services provided to the patient on June 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the manual wheelchair (E1161) and reclining back (E1225) provided on September 10, 2021.
You asked the Plan to pay for the manual wheelchair and reclining back. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these codes were not billed with the appropriate modifiers.
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 E1161 and E1225 is not supported in the medical record. Specifically, the items at issue are considered capped rental items. These codes have been billed with the modifier for new equipment. It is not appropriate to bill the modifier for new equipment with capped rental items. Based on this information, we decided that Medicare rules for coverage of the manual wheelchair and reclining back have not been met.
Therefore, we decided that the Plan does not have to pay for the manual wheelchair (E1161) and reclining back (E1225) provided on September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service September 13, 2021.
You asked the Plan to pay for procedure code 62320. You say that this service was coded appropriately and should be paid. The Plan denied your request. The Plan says you have not submitted any clinical records to support payment of this service.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The Plan requested medical records from you on multiple occasions to determine if these billed services were medically necessary. To date, you have not responded to those requests. As a result, we have no records to determine if these services were medically appropriate. Based on this information, we decided that Medicare
rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service September 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on August 9, 2021.
You asked the Plan to pay for the therapeutic or diagnostic injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the medical necessity of the service billed.
The Plan must follow Medicare rules. Medicare rules say that Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation
in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic or diagnostic injection have not been met. Specifically, the documentation submitted does not include any medical records. There is insufficient information to determine if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on August 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cayston.
You asked the Plan to pre-approve Cayston. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Cayston is not covered under the enrollee's Medicare Part B benefit.
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 pre-approve Cayston.
Benefits for Cayston may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.