Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a crown (D2740), and a core buildup (D2950) provided by an out-of-network provider on June 11, 2021.  You asked the Plan to pay for a crown and a core buildup. You say that you believe you should only owe a 30% coinsurance. The Plan denied your request. The Plan says the dental services that were provided are not covered 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 pay for a crown (D2740), and a core buildup (D2950) provided by an out-of-network provider on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transforaminal epidural steroid injections (TFESIs) represented by codes 64483-RT and 64484-LT.  You asked the Plan to pre-approve TFESIs. You say that the enrollee's MRI revealed severe lateral recess stenosis at L4 and L5. The Plan says that the documentation provided supports the need for the injection services in dispute. The Plan denied your request. The Plan says it is not medically necessary to perform transforaminal epidural steroid injection (TFESI) services at more than 2 nerve root levels during the same session.  The Plan follows Medicare rules. Medicare rules say that it is not considered medically reasonable and necessary to perform TFESIs at more than two nerve root levels during the same session.  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 TFESIs. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is experiencing low back pain with radiculopathy.  The enrollee's magnetic resonance imaging (MRI) revealed severe lateral recess stenosis at L4 and L5.  The plan is for bilateral TFESIs at L4 and L5 levels. Of note, the plan agreed to pre-approve codes 64483-RT and 64483-LT (transforaminal epidural steroid injection, with imaging guidance, lumbar, single level). Bilateral TFESIs at one level are reasonable and medically necessary for the evaluation and treatment of the enrollee.  The review has determined that the requested bilateral TFESIs at the 2nd nerve root level are not medically reasonable and necessary.  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 TFESIs that were denied have not been met. Therefore, we decided that the Plan does not have to pre-approve transforaminal epidural steroid injections (TFESIs) represented by codes 64483-RT and 64484-LT.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a maxillofacial prosthetic procedure (21089).  You asked the Plan to pre-approve the maxillofacial prosthetic procedure. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is non-covered.  Medicare generally does not cover dental services. The Plan follows the same rule.  The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Furthermore, an occlusal orthotic appliance has already been approved. Therefore, we decided that the Plan does not have to pre-approve a maxillofacial prosthetic procedure (21089).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pharmacogenomic testing provided on July 8, 2021.  You asked the Plan to pay for the pharmacogenomic testing. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel.  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 pay for the pharmacogenomic testing. 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 clinical rationale for the requested genetic testing.  The outcome of this testing will not affect the member's treatment.  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 pharmacogenomic testing have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomic testing provided on July 8, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for cardiopulmonary resuscitation (92950) provided December 16, 2020.  You asked the Plan to pay for the cardiopulmonary resuscitation. You say that the services were medically necessary. The Plan denied your request. The Plan says no medical records were provided to support the billed services.  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. You can find this rule at 42 CFR, Section 424.5.  We looked at the file and Medicare rules. Multiple requests for medical records were sent by the plan and none were received to verify the services provided. Based on this information, we decided that Medicare rules for coverage of the cardiopulmonary resuscitation have not been met. Therefore, we decided that the Plan does not have to pay for cardiopulmonary resuscitation (92950) provided December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an additional unit of hospital care (99233) provided on January 30, 2021.  You asked the Plan to pay for an additional unit of hospital care. You say that this is supported in the records. The Plan denied your request. The Plan says this was previously paid.  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 an additional unit of CPT code 99233 is not supported in the medical record. The medical record only supports 1 unit of CPT code 99233, which was previously billed and paid. Based on this information, we decided that Medicare rules for coverage of an additional unit of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an additional unit of hospital care (99233) provided on January 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on June 24, 2021.    You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a physician assistant, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter.  You asked the Plan to pre-approve the scooter. You say that you are unable to walk. The Plan denied your request. The Plan says this device is paid for once every five years.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial of a manual wheelchair. The documentation indicates the ability to walk 40 feet at a time with a rollator. The wheelchair evaluation does not reveal that you can safely maneuver the requested four wheeled scooter in the home through the doorway entrances and around the home to participate in MRADLs. The documentation currently does not support that you need a new scooter less than five years after receiving a power mobility device.  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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Myopro device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational devices are not covered by Medicare.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of hemiparesis from the patient's spinal cord injury than any available standard therapy such as conventional treatments. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in patients with spinal cord injuries.

There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Myopro device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for frames provided on June 11, 2021.  You asked the Plan to pay an additional amount for frames. You say that the frames should be covered in full.  The Plan denied your request. The Plan says you did not purchase a frame from the Genesis collection. The billed amount was $130.00 and after the $50.00 allowance and a 20% savings was applied, your out-of-pocket expense was $50.40.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and the Plan's rules. The file shows that the Plan processed the claim with the correct cost share based on your vision benefit. Therefore, we decided that the Plan does not have to pay an additional amount for frames provided on June 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the laboratory work provided on August 12, 2021.  You asked the Plan to waive the copayment for the laboratory work. You say that you do not believe this service was performed at the time of the physical and you do not believe you should pay for this. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment per day for other Medicare-covered laboratory tests that are not fecal immunochemical tests (FIT).    You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows the pap specimen was collected and tested. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory work provided on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional power wheelchair accessories (K0108, E2311, E2313, E2377) for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says upper limb strength and function are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of the power options.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the K0108 wheelchair transport brackets are not primarily medical in nature and are not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR ?411.15(k) as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. In terms of E2311, E2313, E2377 - the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.).The patient does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests but the enrollee does not need to control the power options through a joystick. The enrollee's upper extremity strength and function with independence in feeding support that the patient can control any power options through 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (K0108, E2311, E2313, E2377) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that you need rehabilitation due to stoke and health reasons. You state you cannot take care of yourself as you are too weak to walk. The Plan denied your request. The Plan says the stay is not medically necessary.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not medically necessary.

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on August 3, 2021.  You asked the Plan to pay for CT scan 70450. 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 70450 has a procedure-to-procedure (PTP) edit of 1 with code 70496 so is not separately payable without an appropriate modifier.  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 CT scan 70450 is a column II code to column I code 70496. 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 a computed tomography (CT) scan (70450) provided on August 3, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for laboratory testing provided on June 9, 2021.  You asked the Plan to pay for lab tests. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the Plan cannot determine how the enrollee came to this provider or whether the testing was medically necessary.  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.  This testing was ordered by an in-network provider. The file does not show that the plan provided notice that lab tests would not be covered. Under Medicare rules, this means lab tests is considered approved by the plan. Therefore, we decided that the Plan has to pay for laboratory testing provided on June 9, 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 pay for the subsequent nursing facility care (99309) provided on August 27, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that the treatment received was medically necessary for the enrollee and the physician has submitted a statement of medical necessity and medical records to justify the reason for the enrollee's stay. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on August 27, 2021 by an out-of-network (OON) provider.