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

 We decided that the Plan does not have to pay for the emergency department visit for the evaluation and management of a patient (CPT code 99283) and radiologic examination; toe(s), minimum of 2 views (CPT code 73660) provided to the enrollee on July 8, 2020, by an out-of-network provider.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  The claims have no G0 modifier billed which is a necessary requirement. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit for the evaluation and management of a patient (CPT code 99283) and radiologic examination; toe(s), minimum of 2 views (CPT code 73660) provided to the enrollee on July 8, 2020, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 24, 2021.  You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the medical records do not support the need for this item.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The supporting documentation must include subjective and objective beneficiary specific information used for diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered. Review of the file shows that the medical records do not support the need or justification for the brace provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that a Group 2 PWC is covered when specific criteria are met.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the records are conflicting regarding whether you have a mobility deficit that significantly impairs your ability to complete mobility-related activities of daily living (MRADLs) in the home. The records do not contain a detailed musculoskeletal or neuromuscular exam that indicates a mobility deficit cannot be helped by a walker or manual wheelchair. The physical evaluation note dated October 6, 2021 states you are able to care for yourself and have no difficulty walking, fatigue, weakness, or shortness of breath while walking. The criteria for coverage are not met and the requested PWC is not reasonable or medically necessary at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the exercise classes (S9451) provided from April 8, 2021, to August 1, 2021.  

You asked the Plan to pay for the exercise classes. You say that you called member services and were told that this facility was in-network, and you could file a claim for reimbursement. The Plan denied your request. The Plan says you did not contact the Plan's fitness vendor in order to activate your benefits and get your member code prior to services, and the facility in this case is not part of the program's network.  

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only when they are received through the Plan's specified fitness program network.   

The Plan's rules for coverage of gym benefits have not been met because the facility in this case does not participate in the Plan's specified program network. It also does not appear that you activated these benefits with your program prior to services. Therefore, we decided that the Plan does not have to pay for the exercise classes (S9451) provided from April 8, 2021, to August 1, 2021.   

Your complaint about potential misinformation from a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on May 26, 2021.

You asked the Plan to pay for the eye refraction. You say that you did not know you would owe money for this service. The Plan denied your request. The Plan says Medicare does not cover routine vision services such as eye refractions. The requested service was provided as part of a medical eye exam and therefore is not a covered service under Medicare or your Plan. In addition, the submitted documentation includes and advanced beneficiary notice (ABN) which includes your signature and provides information that the eye refraction is not a covered service, and you are responsible for the costs. However, the Plan has confirmed with the provider that you owe $50 for this service per this document, and not $55 as previously billed.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided as part of a routine eye exam and performed by a provider who participates in the Plan's routine vision network. 

We looked at the file and the Plan's rules. The vision services provided on the date in question were billed with medical diagnoses and were medical (non-routine) in nature. Neither Medicare nor the Plan cover eye refractions with medical eye exams. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0483) provided on May 3, 2021.  You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and periapical x-ray
(D0220) provided on July 8, 2021.

You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied
your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that
periapical x-ray 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 limited oral evaluation and
periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pay for the limited oral evaluation (D0140), and periapical x-ray (D0220) provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the testing services rendered on September 13, 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 code 95938 is 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 95938 is short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs.  We find that CPT code 95938 is not supported in the medical record. Specifically, there is no documentation of a short-latency somatosensory evoked potential study. 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 testing services rendered on September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical pathology services (88305) provided on August 23, 2021.  You asked the Plan to pay for surgical pathology services. You say that this is a separately payable service. The Plan denied your request. The Plan says this cannot be paid as billed.  The Plan must follow Medicare rules. Medicare rules say that only the hospital may bill for the technical component (TC) of a physician pathology service provided to an inpatient or outpatient.  We looked at the file and Medicare rules. The record shows that the enrollee was a hospital outpatient at the time of service, but this service was not billed with a modifier to indicate that the technical component is not being billed. Based on this information, we decided that Medicare rules for coverage of surgical pathology services have not been met. Therefore, we decided that the Plan does not have to pay for surgical pathology services (88305) provided on August 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested IRF care have not been met.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99215) osteopathic manipulation (98929) telephone evaluation and management visit (99443) provided September 30, 2021, to October 11, 2021.  You asked the Plan to pay for the naturopath services. You say that this has always been covered in the past without an issue and should be covered. The Plan denied your request. The Plan says the services exceed the Plan's benefit frequency limitation.  The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for the services of a naturopath only when billed by a licensed Naturopath practicing within their scope of license, limited to 6 visits/services every calendar year.       We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the naturopath services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99215) osteopathic manipulation (98929) telephone evaluation and management visit (99443) provided September 30, 2021, to October 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) care
admission and services.

You asked the Plan to pre-approve IRF care. You say that you believe going home with home health services
or to a skilled nursing facility (SNF) for therapy would not meet the enrollee's current needs for intensive
therapy and medical management; it is medically necessary for the enrollee to be admitted to an IRF. The Plan
denied your request. The Plan says the enrollee would not be able to tolerate the minimum requirement of three
hours (3) of therapy daily. The Plan states the enrollee is unlikely to decline by not getting such intensive and
fast-paced therapy. The Plan states it is their suggestion that the enrollee seeks admission to a SNF where the
pace of rehabilitation and therapy can be done in a gentler and more gradual way more in line with the
enrollee's current level of tolerance.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for
an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) care admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the power seat elevation (E2300), expandable controller (E2377) and harness upgrade (E2313) provided on May 10, 2021.  You asked the Plan to pre-approve the power seat elevation, expandable controller and harness upgrade. You say that you would like reconsideration because the requested accessories are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the requested accessories.  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 power seat elevation, expandable controller and harness upgrade. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the enrollee meets the criteria detailed in the Wheelchair Options/Accessories - Policy Article (A52504) for the requested accessories. The power seat elevation feature is statutorily non-covered by Medicare as it is not primarily medical in nature. The expandable controller and harness are not covered as provided records document that the enrollee has 3/5 bilateral upper extremity strength and is independent with eating, dressing, grooming, toileting and bathing thus indicating she has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches.   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 power seat elevation, expandable controller and harness upgrade have not been met. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation (E2300), expandable controller (E2377) and harness upgrade (E2313) provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network (OON) provider on April 7, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service 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 this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network (OON) provider on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the coronavirus test provided on August 26, 2021.  You asked the Plan to pay for the coronavirus test. You say that you believe that these services should be covered as they were necessary for traveling. The Plan denied your request. The Plan says coronavirus testing for travel is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Corona Virus testing have not been met. Specifically, the record does not show that a provider ordered this testing due to medical necessity. Coronavirus testing for travel is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the coronavirus test provided on August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the MSH2 gene analysis coded 81295 and the MSH6 gene analysis coded 81298 provided on May 6, 2021.  You asked the Plan to pay for the MSH2 gene analysis and the MSH6 gene analysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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, we have confirmed that code 81295 and 81298 are column II codes to column I code 81432. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the MSH2 gene analysis coded 81295 and the MSH6 gene analysis coded 81298 provided on May 6, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy, 60 minutes with patient (CPT code 90837) provided to the enrollee on August 27, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Evaluation and management by psychologists is covered by Medicare under the following conditions: *Provider must attempt to consult the attending or primary care physician about the services furnished and document the consent or declination date to consultations, and the date of consultations in the patient's medical record." If consultation with the attending or primary care physician is unsuccessful, document in the patient's medical chart with the date and manner of notification to the physician does not consent If attempts to consult directly with the physician are not successful, to notify the physician, within a reasonable time, that he or she is furnishing services to the beneficiary. There was no documented contact with the attending/primary care physician. A referral form or reference to a copy of the report available to a physician does not satisfy the documentation criteria. There is no referring physician listed on the claim. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy, 60 minutes with patient (CPT code 90837) provided to the enrollee on August 27, 2021.