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

 We decided that the Plan does not have to pay for the automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided January 28, 2021.  You asked the Plan to pay for the automatic external defibrillator. You say that you are requesting reconsideration of the denied DME supply for the enrollee's non-ST elevation (NSTEMI) myocardial infarction. The Plan denied your request. The Plan says the request is not medically necessary because the records show the enrollee does not have an ejection fraction less than or equal to 35%.  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 automatic external defibrillator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee has a history of bradycardia and hypotension. She had an MI in 2020 and her most recent ejection fraction was 55-60%. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.  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 automatic external defibrillator have not been met. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for Procalcitonin testing (CPT code 84145) provided to the enrollee on June 3, 2021.  You asked the Plan to pay for the testing. You say that the services were necessary, and they were denied as experimental in error. The Plan denied your request. The Plan says the clinical value and effectiveness of Procalcitonin testing has not been demonstrated in the peer-reviewed literature.  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 testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Procalcitonin is helpful in the setting of suspected severe infection, however, it has not been shown to be conclusive at ruling out sepsis by itself.  Also, the enrollee's history and findings suggested no sepsis or infection of any kind. Therefore, this request for procalcitonin will be considered 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 the testing have not been met. Therefore, we decided that the Plan does not have to pay for Procalcitonin testing (CPT code 84145) provided to the enrollee on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to issue reimbursement for the nail trimming services (11719) rendered by the out-of-network (OON) provider on December 19, 2019, February 12, 2020, October 15, 2020, and December 28, 2020.  You asked the Plan to issue reimbursement 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 issue reimbursement 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 issue reimbursement for these services. Therefore, we decided that the Plan does not have to issue reimbursement for the nail trimming services (11719) rendered by the out-of-network (OON) provider on December 19, 2019, February 12, 2020, October 15, 2020, and December 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF care. You say that the enrollee needs daily physical, occupational and speech therapy due to her head injury. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.

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 the enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs can be provided at a lower level of care. 

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 skilled nursing facility (SNF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on November 19, 2020.    

You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when 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 a physical therapy assistant (PTA) 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 physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on November 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0481) provided on June 3, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for drug testing. The Plan denied your request. The Plan says the referring provider involved in these services is a non-participating provider with the Plan. The Plan did not authorize any services for these providers.  

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 drug testing (G0481) provided on June 3, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a surgical placement of an implant body (D6010), an interim abutment (D6051) and an alveoloplasty in conjunction with extractions (D7311).  

You asked the Plan to pre-approve a surgical placement of an implant body, an interim abutment and an alveoloplasty in conjunction with extractions. You say that the dental services requested are affecting your health and are medically necessary. You also say that a bone spur is coming up from the tooth and you have an infection in your tooth. The Plan denied your request. The Plan says the requested dental services are not covered under your benefit Plan.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical placement of an implant body (D6010), an interim abutment (D6051) and an alveoloplasty in conjunction with extractions (D7311).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) of the orbit, face, and/or neck; without contrast (70543)  provided on July 20, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for a magnetic resonance imaging of the orbit, face, and/or neck; without contrast. You say that the underlying focus of obtaining an authorization is to assure the insurance carrier that the services provided are medically necessary, chich clearly is the case in this situation. The Plan denied your request. The Plan says there is no referring provider, and a referral was not authorized by the primary contract provider.  

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 a magnetic resonance imaging (MRI) of the orbit, face, and/or neck; without contrast (70543)  provided on July 20, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for over the counter supplies purchased from a retail supermarket on August 5, 2021.

You asked the Plan to pay for these supplies. You say that these supplies were medically necessary. The Plan denied your request. The Plan says medical supplies must be purchased from a Medicare approved provider for reimbursement.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided by a vendor is not a Medicare eligible provider. 

These supplies were not purchased from a Medicare eligible durable medical provider. Therefore, we decided that the Plan does not have to pay for over the counter supplies purchased from a retail supermarket on August 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency ambulance transportation (A0427, A0425) provided on September 6, 2021.  You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you disagree with the copayment. The Plan denied your request. The Plan says the copayment was applied correctly.  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 $350 copayment for ambulance services.   You have been asked to pay a $350 copayment for emergency ambulance transportation. The services at issue fall within the ambulance services benefit category. 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 emergency ambulance transportation (A0427, A0425) provided on September 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound provided on August 17, 2021.  

You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  

We looked at the file and the rules. We find that CPT code 76705 was billed with code 93976. CPT code 76705 may be eligible for payment when billed with this code pair. The claim however, does not indicate the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound provided on August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Coflex 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 there appears to be some concern that these devices are not as effective as surgical decompression and could lead to higher rates of reoperation.  

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 this device is experimental. More research is needed to show safety and efficacy.  

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 Coflex device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to an LTACH.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided indicating medical necessity for LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Echocardiography (93312-26-59) provided on December 2, 2020.
You asked the Plan to pay for code 93312-26-59. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the use of modifier -59 for code 93312.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the Echocardiography (93312-26-59) provided on December 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 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 the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services provided by the physician performing the diagnostic service that the sedation supports (CPT code 99153) provided to the enrollee on June 21, 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 99153 is not separately payable when performed by a physician in a facility setting.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. CPT code 99153 has a Professional Component (PC)/Technical Component (TC) indicator of 3 per the April 2021 National Physician Fee Schedule Relative Value File. CPT code 99153 is not separately payable when performed by a physician in a facility setting. Therefore, we decided that the Plan does not have to pay for moderate sedation services provided by the physician performing the diagnostic service that the sedation supports (CPT code 99153) provided to the enrollee on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression 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 there is no adequate satisfactory pneumatic compression treatment trial using a non-segmented device documented.

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 there are no unique characteristics which would indicate the segmented pump over a standard pump. Based on the medical records provided, there is no documentation that the enrollee has tried and failed at least four weeks of a standard non-segmented lymphedema pump. 

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 a pneumatic compression device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical equipment provided on November 13, 2018 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON medical equipment. You say that the enrollee needed this equipment urgently, and the primary care physician was not responsive to the requests for these items. The Plan denied your request. The Plan says there was no evidence of any contact during the time that these items were purchased to show that there was an issue finding a network provider. There were many network providers able to provide these items. No authorization was requested for OON purchases.
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 medical equipment provided on November 13, 2018 by an out-of-network (OON) provider.