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

We decided that the Plan does not have to pay for the respiratory infectious agent detection rendered on January 22, 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 the services are not covered.

The Plan must follow Medicare rules. The rules say that respiratory pathogen panels with more than 5 respiratory pathogens performed in the Part B outpatient setting are considered not medically necessary. 

We looked at the file and Medicare rules. The file shows that 12-25 pathogens were tested. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory infectious agent detection rendered on January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the scaling and root planing (D4342) for the upper right and lower left quadrants, fluoride varnish application (D1206), and unspecified preventive service (D1999) provided on July 12, 2021.  

You asked the Plan to pay for the dental services. You say that you need these services. The Plan denied your request. The Plan says application of fluoride varnish and unspecified preventive service are not listed as covered service. The Plan says that scaling and root planing are covered once every 2 years, per quadrant. The Plan also says that the frequency limit has been exceeded.  

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 application of fluoride varnish and unspecified preventive service are not among those covered under this benefit. The record shows that the Plan paid for scaling and root planing for the upper right provided on January 16, 2020. The record shows that the Plan paid for scaling and root planing for the lower left quadrant that you received on January 15, 2020. Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4342) for the upper right and lower left quadrants, fluoride varnish application (D1206), and unspecified preventive service (D1999) provided on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on February 25, 2021, by an OON
provider.
You asked the Plan to pay for the office services. You say that services provided were out of medical necessity.
The Plan denied your request. The Plan says the services provided were non-urgent and were not authorized for
a non-network provider. Also, a non-network provider referred the enrollee for services.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
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 office services provided on February 25, 2021, by
an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from February 18, 2022, forward.

You asked the Plan to pre-approve SNF care. You say that you cannot return to your assisted living facility due to inability to walk, and an open wound. The Plan denied your request. The Plan says while you may benefit from continuing physical, occupational, and speech therapy, the records do not support the need for daily therapy on an inpatient basis.

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 no longer qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical matter, 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 continuation of SNF care from February 18, 2022, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to lower the coinsurance for a continuous glucose monitoring (CGM)
external transmitter provided on September 30, 2021.
You asked the Plan to lower the coinsurance for a CGM external transmitter. You say that the item is classified
wrong, and you paid a lower price before under a different Plan. The Plan denied your request. The Plan says
the prior purchase was under a different Plan and was processed as the same benefit, but the prior Plan had a
$25 copayment. The proper coinsurance was applied for this item.
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 20%
coinsurance for Durable medical equipment (DME) and related supplies. The total amount allowed was
$609.51 with a coinsurance of $121.90 ($609.51 total amount x 20% coinsurance). Therefore, the proper
amount of $121.90 is correct for the 20% coinsurance of this item.
You have been asked to pay a 20% coinsurance for a CGM external transmitter. A CGM external transmitter
falls within the Durable medical equipment (DME) and related supplies 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 lower the coinsurance for a continuous glucose monitoring (CGM) external transmitter
provided on September 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the repair, of a flexor tendon, leg; primary, without graft, each tendon (27658) and the open treatment of a distal fibular fracture, includes internal fixation, when performed (27792) rendered by the out-of-network (OON) provider on September 14, 2021.  You asked the Plan to pay 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 pay for these services. Therefore, we decided that the Plan does not have to pay for the repair, of a flexor tendon, leg; primary, without graft, each tendon (27658) and the open treatment of a distal fibular fracture, includes internal fixation, when performed (27792) rendered by the out-of-network (OON) provider on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan provided on June 24, 2021.

You asked the Plan to pay for the duplex scan. You say that two separate services were provided The Plan denied your request. The Plan says it cannot be separately reimbursed.

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.

In this case, the CPT Code Manual definition of code 93971 is duplex scan of extremity veins including responses to compression and other maneuvers, unilateral or limited study. The medical records do not show that the service billed with the -59 modifier is a distinct procedural service. The records show that the duplex scan was used to map out the insufficient vein during the endovenous ablation procedure. 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 duplex scan provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection services (64494) provided July 27, 2021.  You asked the Plan to pay for the injection services. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says this claim has been billed incorrectly.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 64494 is 1 The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services (64494) provided July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on November 2, 2021.  

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on  November 2, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit provided on October 8, 2021.  

You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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.       

You have been asked to pay a $90 copayment for an emergency room visit. 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 an emergency room visit provided on October 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on August 19, 2021.  You asked the Plan to pay for this equipment. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care or equipment.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 durable medical equipment provided to the enrollee on August 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from February 20, 2022, forward.

You asked the Plan to pre-approve SNF care. You say that you came in with a stroke, had four (4) urinary tract infections, and have not done any physical therapy (PT) until a few days ago. You state the facility is concerned that if you go home, you will not get proper PT you are needing. The Plan denied your request. The Plan says the stay is not medically necessary. The Plan states your request does not meet Medicare guidelines because there are no noted daily skilled complex nursing or therapy needs which would meet the guidelines for continued SNF services. The Plan states while you may benefit from continuing physical, occupational, and speech therapy, the records do not support the need for daily therapy on an inpatient basis.

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 no longer qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of you condition. Your care needs, custodial and intermittent, can, as a practical matter, 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 continuation of SNF care from February 20, 2022, forward.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity (J3111).
You asked the Plan to pre-approve Evenity. You say that the requested drug is medically necessary. The Plan
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Forteo.
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 Evenity. Our reviewer says that the step
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate
that the enrollee has tried and failed the required drug, Forteo. The reviewer also found that there is no
documentation provided indicating that the plan's required drug would likely be less effective and/or likely
have adverse effects for the enrollee. Therefore, the reviewer found that the Plan's step therapy criteria have not
been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Evenity have not been met. Specifically, the file does not indicate that the
enrollee has tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-
approve Evenity (J3111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a tooth extraction provided by an out-of-network provider on November 8, 2021.  You asked the Plan to pay for a tooth extraction. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered dental service is not a covered dental benefit.  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 tooth extraction provided by an out-of-network provider on November 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) continuation stay provided from July 26, 2021, to August 24, 2021.  You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee was no longer receiving skilled services.  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 pay for the SNF care. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) continuation stay provided from July 26, 2021, to August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on July 27, 2021.  You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical equipment have not been met.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in the patient's medical record adequately supports the medical necessity for the item.  The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The medical records provided do not discuss the item at issue. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen tank (E1392).  You asked the Plan to pre-approve a portable oxygen tank. You say that the item is medically necessary. The Plan denied your request. The Plan says duplicate or redundant durable medical equipment such as oxygen device when the second item performs the same function as the one currently provided to the enrollee is not covered.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  The file shows that you have an oxygen tank. an oxygen tank serves the same purpose as a portable oxygen tank. Specifically, the Plan is already providing the member with the most appropriate equipment to meet their needs. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen tank (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G myoelectric prosthesis (L8702).

You asked the Plan to pre-approve a MyoPro device. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item 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 a MyoPro device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro will improve the long-term outcomes for the 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 a MyoPro device have not been met.

Therefore, we decided that the Plan does not have to pre-approve a MyoPro 2 Motion G myoelectric prosthesis (L8702).