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

We decided that the Plan does not have to pre-approve the MyoPro device (L8702).

You asked the Plan to pre-approve the MyoPro device. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is experimental.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MyoPro device. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, 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 the MyoPro device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) provided on August 13, 2021.

You asked the Plan to pay for MRI. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 77049 returns an edit of 62 for a code not recognized for outpatient prospective payment system (OPPS).

The Plan must follow Medicare rules. Medicare rules say that code 77049 is not recognized for payment through the OPPS and results in the claim being returned to the provider until the problem is corrected. 

We looked at the file and Medicare rules. This code is not recognized for payment through the OPPS and the claim is returned to the provider until this problem is corrected. Based on this information, we decided that Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to pay for magnetic resonance imaging (MRI) provided on August 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not tried and failed Synvisc or Orthovisc.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Euflexxa. Our physician reviewer found that the enrollee has chronic pain in the left knee. The Plan requires a trial of Synvisc or Orthovisc before they will approve the requested drug. The documentation does not support that the enrollee has tried and failed Synvisc or Orthovisc. The documentation does not support that Synvisc or Orthovisc would likely be less effective or would likely have adverse effects for the enrollee in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
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 SNF services. You say that you need rehab for assistance so you can stabilize. The Plan denied your request. The Plan says that the services you require can safely be received at a different setting.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 pay for radiology services received on July 28, 2021.

You asked the Plan to pay for the services. You say that your doctor informed you to see this doctor while in Florida for CT scan and surgery as soon as possible. The Plan denied your request. The Plan says this service was not urgent or emergent.

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 rendering 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 radiology services received on July 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy (PT) services.

You asked the Plan to pre-approve the continued PT services. You say that the enrollee has been progressing with PT services and would benefit from continued skilled therapy services to progress toward her goals and promote improved independence through balance and strength training. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage. The Plan also says that the enrollee's reasonable functional goals and expected outcomes have been achieved.

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 the continued PT services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the patient has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. Our reviewer found that the patient and caregiver can participate in a home exercise program. Our physician reviewer also found that the requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.

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 continued PT services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy (PT) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continued skilled nursing facility (SNF) services provided July 15, 2021 to August 15, 2021.

You asked the Plan to pay for the SNF services. You say that you feel that the Plan should cover for the SNF services. The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.

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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 pay for continued skilled nursing facility (SNF) services provided July 15, 2021 to August 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional hours of neuropsychological testing (96133, 96139).

You asked the Plan to pre-approve neuropsychological testing. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.

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 neuropsychological testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that you are asking for an excessive amount of the procedure beyond which is approved under Medicare rules. This patient has shown an impairment in functioning as documented. He has been showing difficulty with memory issues. Based on the records provided, the enrollee does not meet the criteria for additional neuropsychological testing. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pre-approve additional hours of neuropsychological testing (96133, 96139).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis (20610) provided on March 1, 2021.

You asked the Plan to pay for arthrocentesis. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is a duplicate claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.

We find that 2 additional units of CPT code 20610 are not supported in the medical record. The medical record only supports 2 units of CPT code 20610, which were previously billed and paid. Based on this information, we decided that Medicare rules for coverage of arthrocentesis have not been met. Therefore, we decided that the Plan does not have to pay for arthrocentesis (20610) provided on March 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve these services. 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 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 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 services at issue in this appeal.
We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be rendered by the out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the home health aide (S9122) services provided on July 16, 2021.

You asked the Plan to reimburse you for the home health services. You say that you feel the service should be covered and you should be reimbursed. The Plan denied your request. The Plan says there is no referral on file from a doctor certifying the home health care service. The Plan also says that the claim was denied correctly.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the file does not show that a doctor certified home health care services with the health plan. Therefore, we decided that the Plan does not have to reimburse you for the home health aide (S9122) services provided on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neurology consultation to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the neurology consultation. You say that you are requesting to see an out-of-network provider due to an arachnoid cyst. The Plan denied your request. The Plan says the provider is out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the neurology consultation to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. 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 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 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 services at issue in this appeal.

We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve ophthalmology services to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alternative switchbox (K0108) and an attendant control (E2331).
You asked the Plan to pre-approve an alternative switchbox and an attendant control. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested items have not been met.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The rules also say that an attendant control provided in addition to a beneficiary-operated drive control system is not covered.
The file shows that the enrollee has been approved for a head control interface, proximity switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware (E2330). A head control interface serves the same purpose as an alternative switchbox. Furthermore, a head control interface is a beneficiary-operated control system. Therefore, we decided that the Plan does not have to pre-approve an alternative switchbox (K0108) and an attendant control (E2331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).

You asked the Plan to pre-approve the complete dentures. You say that the enrollee's dentures broke in October and the enrollee was advised that they are not repairable. The Plan denied your request. The Plan says these services are allowed one time every 60 months. The Plan also says that you received these services less than 60 months ago.

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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to once per 60 months. The record shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on May 6, 2019 and the enrollee's complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dermatology visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the dermatology visit. You say that the in-network providers are unable to identify and treat diagnosis your condition. The Plan denied your request. The Plan says the provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the dermatology visit to be provided by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88305, 88342) rendered by the out-of-network (OON) provider on July 22, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The 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 laboratory services (88305, 88342) rendered by the out-of-network (OON) provider on July 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexamethasone for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under 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 pre-approve Dexamethasone for the enrollee.
Benefits for this drug 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 the laboratory services (81191, 81317, 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, and 81311) provided on April 26, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.

Specifically, this claim was billed with the laboratory place of service code while the records indicate that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (81191, 81317, 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, and 81311) provided on April 26, 2021.