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

We decided that the Plan does not have to pay for Psychotherapy provided by a Licensed Clinical Social
Worker on January 13, 2021.
You asked the Plan to pay for psychotherapy (90834). You say that you would like the Plan to review the
medical records and reconsider payment. The Plan denied your request. The Plan says payment for clinical
psychologist's services is limited to treatment by practitioners with a Psychology Doctoral degree.
The Plan follows Medicare rules. The rules say that Medicare doesn't cover CSW services to SNF inpatients.
In this case, the record shows the enrollee was inpatient in a SNF at the time of service. Therefore, we decided
that the Plan does not have to pay for Psychotherapy provided by a Licensed Clinical Social Worker on January
13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shoe lift.
You asked the Plan to pre-approve a shoe lift. You say that you are unable to walk straight because you have
had two hip joint surgeries. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve a shoe lift.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on May 20, 2021, by an OON
provider.
You asked the Plan to pay for podiatry services. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says prior authorization was not obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for podiatry services provided on May 20, 2021, by an
OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology procedures (88120) provided September 21, 2020.
You asked the Plan to pay for the screening testing services. You say that the claim was denied for inconsistent diagnosis with procedure and the medical records provided support the necessity of the services. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, the screening testing services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the cytopathology procedures (88120) provided September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702).
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is experimental/investigational.
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 MyoPro orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. 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 the 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 a MyoPro orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas neoGEN Series Therapy services provided on
September 30, 2020.
You asked the Plan to pay for the Sanexas neoGEN Series Therapy services. You say that you would like
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the
billed service does not meet Medicare criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT codes 99211, 97112, 97032, 97016, 96375, J3490, J3415, and J3411 are not supported in the
medical record. Specifically, review of the file and publicly available records, we find that the physical therapy
services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the
State of Ohio. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin
syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999.
As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as
billed, the drug administration code, 96375, also cannot be paid. Finally, the office visit at issue was billed with
modifier 25, which is used to report a significant, separately identifiable Evaluation and Management (EM)
service by the same physician or other qualified health care professional on the same day of a procedure or
other service. There is no documentation of any significant, separately identifiable evaluation unrelated to the
treatment provided to the enrollee on this date of service. Based on this information, we decided that Medicare
rules for coverage of the Sanexas neoGEN Series Therapy services have not been met. Therefore, we decided
that the Plan does not have to pay for Sanexas neoGEN Series Therapy services provided on September 30,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intermittent limb compression device.
You asked the Plan to pre-approve intermittent limb compression device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of swelling in the legs.
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. The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve intermittent limb compression device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transportation (A0998) provided on March 20, 2021.
You asked the Plan to pay for the ambulance response and treatment without transport. You say that you needed help getting up from a fall and felt fine after you were assisted. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. If you are not transported, there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 20, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without transportation (A0998) provided on March 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99211-25), therapy services (G0283, 97112),
and injections (96372, J3490, J3420, J3415, J3411, J2001, J1955) provided on August 14, 2020.
You asked the Plan to pay for an office visit, therapy services, and injections. You say that these services
should be covered. The Plan denied your request. The Plan says these services are experimental.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical
therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private
practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that
NP/PA may perform physical therapy services under State law. Claims for compounded drugs shall be
submitted using a compounded drug, not otherwise classified (NOC) code. Modifier 25 is defined as a
significant, separately identifiable Evaluation and Management (EM) service by the same physician or other
qualified health care professional on the same day of a procedure or other service.
We looked at the file and Medicare rules. The records do not show that the therapy services at issue were
provided by a physical therapist or a provider licensed to provide therapy services under state law. The records
show that the injections at issue were compounded drugs and should be reported using a compounded drug, not
otherwise classified (NOC) code. The office visit at issue was reported with modifier 25, but the records tdo
not support that there was a significant, separately identifiable EM service. Based on this information, we
decided that Medicare rules for coverage of an office visit, therapy services, and injections have not been met.
Therefore, we decided that the Plan does not have to pay for an office visit (99211-25), therapy services
(G0283, 97112), and injections (96372, J3490, J3420, J3415, J3411, J2001, J1955) provided on August 14,
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Synvisc (J7325).

You asked the Plan to pre-approve Synvisc. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for Synvisc have not been met.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Synvisc. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee has knee pain from a meniscal tear. The Food and Drug Administration has not approved the requested service for that indication. The Medicare approved drug compendia do not contain a positive citation for the requested service for the noted indication. The elements of the coverage criteria are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Synvisc (J7325).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on March 22, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination within the allotted time frame.
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. The enrollee was referred for the laboratory services by a contract provider. The file does not show that the plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the laboratory services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the laboratory services provided on March 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural injections (64483).
You asked the Plan to pre-approve lumbar epidural injections. You say that physical therapy has not been helping you. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that coverage of lumbar epidural injections requires an appropriately comprehensive evaluation of all potential contributing pain generators and treatment in accordance with an established and documented treatment plan and, with limited exceptions, failure of four weeks (counting from onset of pain) of non-surgical, non-injection care, which includes appropriate oral medication(s) and physical therapy to the extent tolerated. We looked at the file and Medicare rules. Medical records have not been received from you provider showing that you have had an appropriate evaluation and that your physical therapy and other conservative treatments have spanned four weeks. Based on this information, we decided that Medicare rules for coverage of lumbar epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural injections (64483).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on March 5, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility for a scheduled appointment for dementia is not a Medicare covered benefit.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically reasonable and necessary Our physician reviewer found per the reviewed documentation, that the enrollee was picked up at a physician's office at 10:30 AM then taken to the nursing home at 12:57 PM due to altered mental status. The
enrollee is bed confined, unable to get up from bed without assistance or sit in a wheelchair for a long period of time. The enrollee also required supervision due to a condition that places the enrollee and others at a risk of harm for the duration of the transport. The review has determined that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation did not support that the ambulance transport on March 5, 2021 was medically reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on March 8, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 medical services provided to the enrollee on 
March 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pulmonary rehabilitation.
You asked the Plan to pre-approve pulmonary rehabilitation. You say that you are asking the Plan to consider your Gold status as an indicator of the severity of your symptoms and impact on your quality of life. You say that you have dyspnea while walking on level ground, needing to take breaks and you walk slower than your peers. You say that you do not feel that your mild degree of COPD and emphysema demonstrated on pulmonary function tests and imaging accurately reflects the severity of your disease. The Plan denied your request. The Plan says diagnosis of mild COPD (J44.9) does not meet the required criteria for coverage of pulmonary rehabilitation.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary pulmonary rehabilitation (PR) programs for those with moderate to very severe COPD. There must be a referral from the doctor treating the disease. The services must be provided in a doctor's office or an outpatient hospital setting. The PR program must include specific components. Benefits are limited to a maximum of 36 visits, with an additional 36 visits if 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 pulmonary rehabilitation. Our reviewer says that pulmonary rehabilitation is not medically necessary. Our physician reviewer found that you have COPD. According to pulmonary function criteria, you have mild COPD, or GOLD class I. Medicare covers pulmonary rehabilitation for patients with COPD class II - IV. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pulmonary rehabilitation have not been met. Therefore, we decided that the Plan does not have to pre-approve pulmonary rehabilitation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L0648, L0180) provided March 22, 2021.
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied your request. The Plan says the items were provided following an unsolicited telehealth call. Coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for orthoses (L0648, L0180) provided March 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) Shoulder elbow wrist hand orthosis (L3960) suspension sleeve (L2397) Lumbar-sacral orthosis (L0648) provided March 24, 2021.
You asked the Plan to pay for the orthoses. You say that the documentation clearly shows medical necessity based on the doctor's review of the enrollee. The Plan denied your request. The Plan says documentation indicates services are not necessary for treatment of the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) Shoulder elbow wrist hand orthosis (L3960) suspension sleeve (L2397) Lumbar-sacral orthosis (L0648) provided March 24, 2021.