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

We decided that the Plan does not have to pre-approve eye movement desensitization and reprocessing (EMDR) psychotherapy.

You asked the Plan to pre-approve EMDR psychotherapy. You say that you have PTSD because of racial discrimination and every time you tell your story, you are told that they do not want to work with you. The Plan denied your request. The Plan says the requested service is not medically necessary at this time as the enrollee does not have a PTSD diagnosis.

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 EMDR psychotherapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review the records provided, it is noted that this patient is diagnosed with persistent depressive with intermittent major depressed disorder, personality disorder, unspecified type, non-compliant with medication regimen and insomnia. Records do not show that she has a diagnosis of post-traumatic stress disorder. Based on review the records provided this enrollee does not require treatment with EMDR psychotherapy as it is not considered standard treatment for her diagnoses. It is therefore not medically necessary or reasonable 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 EMDR psychotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve eye movement desensitization and reprocessing (EMDR) psychotherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology care to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve specialist care. You say that this physician was recommended by your treating provider and you thought this had been approved. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve oncology care to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services coded 99308 and 99309 provided from June 2, 2021, through June 16, 2021.  You asked the Plan to pay for the medical services. You say that these services have been billed appropriately. The Plan denied your request. The Plan says the records do not support the services 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.       In this case, the CPT Code Manual definition of code 99308 is subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient's facility floor or unit. The CPT Code Manual definition of code 99309 is Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit.  We asked our coder 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 medical services. Our reviewer says that the documentation does not support payment for the claims as billed during the dates in question. Our reviewer found the medical records provided do not include sufficient documentation to validate that 99308 and 99309 were performed on during the dates in question. Therefore, these procedures cannot be verified for payment.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded 99308 and 99309 provided from June 2, 2021, through June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (CPT code G0482) provided to the enrollee on September 28, 2021, by an out-of-network providers.

You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

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 drug testing (CPT code G0482) provided to the enrollee on September 28, 2021, by an out-of-network providers.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Humalog kwikpen.  You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Humalog kwikpen.   Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prolonged evaluation and management services (99359) provided on February 1, 2021.  You asked the Plan to pay for the prolonged evaluation and management services. You say that the documentation supports the services as billed. The Plan denied your request. The Plan says this claim has been coded incorrectly.  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 99359 is a column II code to column I code 99310. In this case, the Modifier Indicator is 0 indicating that the column II code cannot be paid regardless of what modifier is used. 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 prolonged evaluation and management services (99359) provided on February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee orthotic (L1851) and extension (L2397), provided on September 15, 2021.  You asked the Plan to pay for the knee orthotic and extension. You say that the item is medically necessary. The Plan denied your request. The Plan says the records show the member does not have any recent trauma, surgery or instability with respect to your knee.  The Plan must follow Medicare rules. Medicare rules say that claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the criteria for coverage listed in the Medicare Rules section of this letter.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthotic and extension have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthotic (L1851) and extension (L2397), provided on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-therapeutic continuous glucose monitor (CGM) sensor (A9276).

You asked the Plan to pre-approve a non-therapeutic CGM sensor. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.

The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a non-therapeutic CGM sensor have not been met. Specifically, the requested CGM device does not meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a non-therapeutic continuous glucose monitor (CGM) sensor (A9276).
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. The Plan denied your request. The Plan says you do not require an interdisciplinary approach to rehabilitation care.  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 physician reviewer found that you were admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Your medical problems are stable. You do not require treatment by multiple therapies in 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.  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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory service (CPT code 80299) provided on April 1, 2021.  You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  CPT code 80299 (1 unit) remains not supported. This code represents a not elsewhere specified code. However, a complete description of the not elsewhere specified code was not included. The order/ lab requisition must include what laboratory test was ordered/requested to validate the not elsewhere specified code billed; therefore, the billed code cannot be verified.  It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we cannot confirm Medicare coverage has been met. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory service (CPT code 80299) provided on April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies rendered on July 19, 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 codes S1015 and S8301 are not covered.  The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.  We looked at the file and Medicare rules. Billed procedure code S1015 (intravenous tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the supplies rendered on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory service (CPT code 83789) provided on March 15, 2021.  You asked the Plan to pay for the laboratory 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.  CPT code 83789 59 (1 unit) remains not supported. This code is included in Healthcare Common Procedure Coding System (HCPCS) code G0480 and CPT code 80307; therefore, it cannot be separately reimbursed. This code is not separately reimbursed when billed for specimen validity testing on urine specimens utilized for drug testing. It is noted multiple attempts were made to obtain additional information from the provider. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory service (CPT code 83789) provided on March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (PMD) (K0822).

You asked the Plan to pre-approve a PMD. You say that the item is medically necessary. The Plan denied your request. The Plan says your records do not show an order for this device and your physician notes that they do not feel you are safe to operate an electric wheelchair.

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.

The file shows that you cannot safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (PMD) (K0822).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids, monaural, in the ear (V5050) provided May 20, 2021.

You asked the Plan to pay for the hearing aids. You say that the Plan's hearing aid supplier does not have the right hearing aids for you. The Plan denied your request. The Plan says these hearing aids are not covered because they were not purchased from the Plan's specified hearing aid supplier.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when you purchase of the specified branded hearing aids from the Plan's hearing aid vendor. 

We looked at the file and the Plan's rules. In this case you purchased hearing aids that were not provided by the Plan's hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids, monaural, in the ear (V5050) provided May 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from August 27, 2021, through August 29, 2021.

You asked the Plan to pay for physician's services. You say that the patient was not enrolled in hospice on these dates of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on August 26, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided from August 27, 2021, through August 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Synvisc (J7325).  

You asked the Plan to pre-approve Synvisc. You say that the requested drug is a medical necessity and most effective for the enrollee's condition. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.  

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drugs Orthovisc or Supartz FX before they will approve the requested drug, Synvisc. Based on the medical records provided, the enrollee has not tried and failed the required drugs. There is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Synvisc (J7325).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 12 additional home health speech therapy visits (G0153).  You asked the Plan to pre-approve additional home health services.. You say that this care remains medically necessary. The Plan denied your request. The Plan says additional home health services beyond what has been approved are not medically reasonable and necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 additional home health services. Our reviewer says that the requested additional home health speech therapy services are not medically reasonable and necessary. Our physician reviewer found that based on the medical records provided there is no documentation that further skilled speech therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration. Provided records do not document any acute or unstable medical conditions or recent changes in medication or treatment which would necessitate any further skilled speech therapy visits beyond what have already been approved. No medical notes from the enrollee's treating physician are provided documenting a need for additional skilled speech therapy services beyond what have already been approved.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health services. have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional home health speech therapy visits (G0153).