Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for comprehensive genomic profile testing provided on March 9, 2021.  You asked the Plan to pay for comprehensive genomic profile testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because comprehensive genomic profile testing should be billed with 1 unit of code 81479 and the approved DEX Z-Code for the testing.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan denied payment for this testing on the basis that MolDx requires comprehensive genomic profile testing to be billed with 1 unit of procedure code 81479 and the approved DEX Z-Code for the testing. However, this billing and coding rule lacks jurisdiction in the geographic location where the testing was performed. The Plan did not provide any other rationale or evidence to support this denial of payment. Furthermore, this testing was ordered by an in-network physician and was therefore plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for comprehensive genomic profile testing provided on March 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 infrared therapy and intravenous (IV) infusion provided on June 14, 2021 to July 13, 2021 by an out-of-network (OON) provider.  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 the services were rendered by an out-of-network provider without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The 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 infrared therapy and intravenous (IV) infusion provided on June 14, 2021 to July 13, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve implantation of a CardioMEMS device (33289, C2624).  You asked the Plan to pre-approve implantation of a CardioMEMS device. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure 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 implantation of a CardioMEMS device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in the enrollee's clinical management.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of implantation of a CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a CardioMEMS device (33289, C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).

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 these 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 enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee 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 support that the enrollee 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 (E2311, E2313, E2377).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99285) provided on August 19, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $90 copayment for emergency care services. 

You have been asked to pay a $90 copayment for the emergency care service provided. 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 emergency room visit (99285) provided on August 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70450) provided August 8, 2021.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 70450 is not supported in the medical record. Specifically, this service was paid on a previous claim. The documentation does not support payment for an additional unit of this service. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (70450) provided August 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (CPT code 99203) and unclassified drugs (CPT code J3490) provided on March 17, 2021.  

You asked the Plan to pay for the services. You say that you were stuck in outside the United States due to the pandemic. The Plan denied your request. The Plan says non-emergent services outside the United States is not covered.  

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.  

You received routine eye services at an outpatient clinic outside the United States. The services are not considered an emergency. This is not covered. Original Medicare does not cover services in a foreign hospital unless the member is in the United States when member need services and foreign hospital is closer or had a medical emergency while traveling outside the United States. The care received would not be covered by Original Medicare. You do have supplemental coverage for emergent services anywhere in the world. You did not have an emergency. You were seen in an outpatient doctor's office outside the United States for a chronic condition. Therefore, we decided that the Plan does not have to pay for the office visit (CPT code 99203) and unclassified drugs (CPT code J3490) provided on March 17, 2021.
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 the enrollee needs to return to maximum level of function before going home. 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 the enrollee has been receiving treatment for seizures and weakness. The care planning documentation indicates the enrollee was modified independent for mobility before their recent illness, however the therapy documentation indicates that the enrollee is too fatigued to give a detailed history. 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 skilled nursing facility. The enrollee is unable to cooperate with therapy services due to fatigue. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. It is unclear if the enrollee's physical function is at or near their baseline and the enrollee can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a knee orthosis (L1843).  You asked the Plan to pre-approve a knee orthosis. You say that the requested knee orthosis is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the criteria for the requested knee orthosis have not been met.  The Plan follows Medicare rules. Medicare rules say that the requested knee orthosis is subject to the criteria listed 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 a knee orthosis. Our reviewer says that the requested orthosis is not medically reasonable and necessary. Our physician reviewer found the documentation does not support that the patient had recent injury to or a surgical procedure to the knee. The documentation does not indicate that the patient has knee instability on an objective physical examination. The criteria for the L1843 have not been met per Local Coverage Determination (LCD): Knee Orthoses (L33318).  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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1843).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 10, 2021.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says there was no genetic testing order on file.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates that the enrollee has a diagnosis of enlarged prostate without lower urinary tract symptoms; Elevated prostate specific antigen [PSA]. The review has determined that the services are not medically necessary in this case. There was no valid physician order in the case file. 

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 pay for laboratory services provided to the enrollee on September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (CPT code 99214-25) provided to the enrollee on July 20, 2021.  You asked the Plan to pay for the service. You say that this provider is a specialist in Osteopathic Manipulation. You state the patients see the doctor for manipulation. You state that the codes are payable for the services provided by the provider. The Plan denied your request. The Plan says the service is not covered as billed.  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. The E/M service must be a significant, separately identifiable E/M service that is above and beyond the usual pre-, intra- and post-operative work of the osteopathic manipulation. The documentation submitted did not indicate that a different anatomical site, a different condition or a related but unusual condition was addressed during the osteopathic manipulation visit. Based on a review of the original claim and Medical Records along with the supporting research, the findings are as follows: Prior findings are upheld for code 99214. Therefore, we decided that the Plan does not have to pay for the office visit (CPT code 99214-25) provided to the enrollee on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the labial veneer (porcelain laminate) - laboratory (D2962) provided August 11, 2021.  You asked the Plan to pay for the labial veneer. You say that your provider told you this service was pre-approved and covered by the Plan. The Plan denied your request. The Plan says this service is not covered under your benefits and the Plan can find no record of an approval.  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 the labial veneer (porcelain laminate) - laboratory (D2962) provided August 11, 2021.   Your complaint about potentially being provided misinformation about coverage from the Plan or a network provider 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: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.  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 the services are medically necessary. Our physician reviewer found the enrollee does require skilled therapy services on a daily basis at a skilled nursing facility to restore function and avoid further decline or complications. Admission to a skilled nursing facility for inpatient rehab services is medically appropriate.  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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.   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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on June 2, 2021.

You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were rendered to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met.

Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on June 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter replacement for the enrollee.  You asked the Plan to pre-approve the replacement. You say that this is medically necessary. The Plan denied your request. The Plan says the current scooter should be repaired.  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 replacement. Our reviewer says that the requested replacement is not medically reasonable or necessary. Our physician reviewer found the documentation does not reveal that the current scooter is irreparable and the request for a new scooter is not medically necessary per the criteria of Medicare Benefit Policy Manual, Chapter 15, Section 100.2 and per Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). The most recent physician progress note indicates that the enrollee walks around the home daily for exercise. Therefore, it is not clear whether she still requires a power scooter to participate in MRADLs in the home, and that any mobility deficit is currently unable to be alleviated with a walker, or manual wheelchair.  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 replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter replacement for the enrollee.