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

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702).
You asked the Plan to pre-approve the orthotic device. You say that this enrollee has exhausted the other available therapies and has not regained meaningful use of his right dominant upper extremity. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, panoramic x-ray and unspecified preventive procedure provided on May 25, 2021.
You asked the Plan to pay for the comprehensive oral evaluation, panoramic x-ray and unspecified preventive procedure. You say that you did not file a dental claim in 2020 and this is your first dental claim of 2021. You say that you want to understand how the service has been satisfied and frequency exceeded. The Plan denied your request. The Plan says reimbursement has already been issued for the comprehensive oral evaluation and complete series x-ray provided on April 29, 2019. The plan also says that the unspecified preventive procedure is not a covered 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, you also have a maximum benefit of one comprehensive oral evaluation every three years and one complete series or panoramic x-ray every five years. The Plan paid for the comprehensive oral evaluation and complete series x-ray provided on April 29, 2019, which exhausted your benefit. The unspecified preventive procedure is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, panoramic x-ray and unspecified preventive procedure provided on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing (81479) provided on October 26, 2020.

You asked the Plan to pay for the GeneSight testing. You say that you would like reconsideration because this testing is covered by Medicare. The Plan denied your request. The Plan says GeneSight Psychotropic has not been shown to be useful, is not considered medically necessary and appropriate, is not covered by Medicare and cannot be approved.

The Plan must follow Medicare rules. Medicare rules say that the present evidence does not clearly demonstrate that routine PGx testing for the purpose of medication selection offers a benefit over selection of medications based on contemporary evidence-based medication selection protocols. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the GeneSight testing have not been met. Specifically, evidence has not shown that PGx testing is a better tool for drug selection than using a standardized evidence-based protocol which does not rely on genetics, or a consultation from a knowledgeable provider. Therefore, we decided that the Plan does not have to pay for the GeneSight testing (81479) provided on October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hospital bed (E0265).
You asked the Plan to pre-approve a hospital bed. You say that the item is medically necessary. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a hospital bed (E0265).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 27, 2021.
You asked the Plan to pay for laboratory services. You say that this is a Medicare covered service. The Plan denied your request. The Plan says this provider is out of network with the Plan and prior authorization was not obtained.
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 laboratory services provided on January 27, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee required total assistant for 
bed mobility and hygiene. The enrollee was non-ambulatory and dependent for transfers. The enrollee has had 
a percutaneous endoscopic gastrostomy since September 13, 2021 and this does not require transfer to a SNF 
for management. The enrollee's functional level does not require skilled therapy services with the specialized 
skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary 
and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or 
a combination of these services) on a daily basis in a SNF. As a practical matter, this enrollee does not require 
the necessary services on an inpatient basis, in a skilled nursing facility 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vascular surgery consultation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the vascular surgery consultation. You say that the service is medically necessary. The Plan denied your request. The Plan says the provider is out-of-network.
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. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the vascular surgery consultation to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 

You asked the Plan to pre-approve the compression stockings. You say that the enrollee has ongoing issues and 
without the help of insurance you are forced to get generic stockings. The Plan denied your request. The Plan 
says the enrollee does not have any open venous stasis ulcers. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code A6531.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit kit for wheelchair. 
 
You asked the Plan to pre-approve a transit kit for wheelchair. You say that you feel you need this item. The 
Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transit kit for wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus immunization you received on May 11, 2021. 
 
You asked the Plan to pay for the tetanus immunization. You say that you were told that you needed to update 
your tetanus immunization, so you had it administered in your doctor's office.  You said that had you know this 
would not be covered, you would have declined this service. The Plan denied your request. The Plan says this 
immunization is not covered under your medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for the tetanus immunization. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the tetanus 
immunization. Therefore, we decided that the Plan does not have to pay for the tetanus immunization you 
received on May 11, 2021.  
 
Benefits for the tetanus immunization 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 initial nursing facility care (99304) and transitional care services (99496) provided on April 15, 2021.
You asked the Plan to pay for the initial nursing facility care and transitional care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 99304 is initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or 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 problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit. The CPT Code Manual definition of code 99496 is Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of high complexity during the service period Face-to-face visit, within 7 calendar days of discharge. 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 initial nursing facility care and transitional care services. Our reviewer says that CPT code 99304 does not meet criteria for billing or reimbursement consideration. The documentation does not support 3 of 3 components required for this procedure. Documentation supports an expanded problem focused history; Comprehensive exam; and moderate medical decision making. Our reviewer found CPT code 99496 does not meet criteria for billing or reimbursement consideration. The documentation does not include enough information to confirm this service has been performed per CPT guidelines. Documentation should include communication, education, assessment and support medication management. 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 initial nursing facility care and transitional care services have not been met. Therefore, we decided that the Plan does not have to pay for initial nursing facility care (99304) and transitional care services (99496) provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
December 31, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this code has 
status indicator equal to X as depicted on the physician fee schedule which is not in the statutory definition of 
"physician services" for fee schedule payment purposes. The billed charges are Home Health Skilled Nursing 
services and must be reported on home health prospective payment system (PPS) claims with a corresponding 
revenue code. Per the above Medicare guidelines, we find the Medicare rule for payment of code G0299 (6 
units) home health skilled nursing services billed on a professional CMS-1500 claim form, for December 31, 
2020, has not been met. Therefore, we decided that the Plan does not have to pay for the home health services 
provided to the enrollee from December 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcatheter insertion or replacement of permanent
leadless pacemaker (33274).
You asked the Plan to pre-approve a transcatheter insertion or replacement of permanent leadless pacemaker.
You say that the services are necessary. The Plan denied your request. The Plan says based on the
documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are non-covered when
furnished outside of a CMS approved CED study.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a transcatheter insertion or replacement of permanent leadless pacemaker have not been met.
Therefore, we decided that the Plan does not have to pre-approve a transcatheter insertion or replacement of
permanent leadless pacemaker (33274).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor supplies 
(K0553). 
 
You asked the Plan to pre-approve Freestyle Libre continuous glucose monitor supplies. You say that this is 
medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
Freestyle Libre continuous glucose monitor supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Freestyle Libre continuous glucose monitor supplies (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup provided on October 5, 2020.

You asked the Plan to pay for the core buildup. You say that they never told you they were no longer in-network, so you proceeded with the dental work. You say that you received a bill and are asking the Plan to retro authorize the claim. The Plan denied your request. The Plan says the claims reprocessed as a one-time exception to cover the crown. The Plan also says that core buildup remains denied as a non-covered 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 the core buildup provided on October 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a transvaginal ultrasound and a duplex scan provided on April 26, 2021.

You asked the Plan to waive the copayments for a transvaginal ultrasound and a duplex scan. You say that you disagree with the charges because you should only owe a $45 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for diagnostic radiology services and a $50 copayment for all other outpatient diagnostic tests. 

You received a transvaginal ultrasound on April 26, 2021. Therefore, you are responsible to pay the $125 copayment.

You received a duplex scan on April 26, 2021. Therefore, you are responsible to pay the $50 copayment. 

The total amount you owe is: $175. 

You have been asked to pay the total copayment amount of $175 for a transvaginal ultrasound and a duplex scan. A transvaginal ultrasound and a duplex scan fall within the outpatient diagnostic tests and therapeutic services and 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 waive the copayments for a transvaginal ultrasound and a duplex scan provided on April 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen.
You asked the Plan to pre-approve computed tomography (CT). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 computed tomography (CT). Our reviewer says that he documentation does not support that the requested CT scan is medically reasonable or necessary. Our physician reviewer found the radiologist report from the CT obtained October 16, 2021 states stable right adrenal gland adenoma. The documentation supports that no further follow-up is necessary. There is no specific clinical rationale for the requested CT scan. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of computed tomography (CT) have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral nerve branches of the sacroiliac (SI) joint.
You asked the Plan to pre-approve the SI joint RFA procedure. You say that this treatment should be allowed given the positive results. The Plan denied your request. The Plan says this is considered an experimental procedure.
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 SI joint RFA procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a female with low back pain/sacroiliitis. She has tried physical therapy and had excellent results with prior RFA procedures. However, this is still considered an experimental/ investigational procedure. Therefore, the request is deemed not medically reasonable or 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 SI joint RFA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral nerve branches of the sacroiliac (SI) joint.