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

 We decided that the Plan does not have to pay for the laboratory services provided on May 5, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services billed are not separately payable.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the SelectMDx testing provided on May 24, 2021.  

You asked the Plan to pay for the testing services. You say that the test distinguishes those at increased risk for prostate cancer. The Plan denied your request. The Plan says screening services without a valid diagnosis are not a covered benefit.  

The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the beneficiary's medical documentation. 

We looked at the file and the rules. In this case, the testing at issue was not supported by medical records. The records do not include previous lab testing, exams, or other documentation to show the testing was indicated. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing provided on May 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided on May 19, 2021
.  
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physical therapy services. 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 physical therapy services provided on  May 19, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided on October 10, 2021, through October 12, 2021.
  
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration because the inpatient services were medically necessary. The Plan denied your request. The Plan says that the documentation submitted does not support that the inpatient level of care was medically necessary.
  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
  
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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided on October 10, 2021, through October 12, 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Synvisc for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements are not met.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. Repeat hyaluronic injections can be covered when medically necessary every six months.  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 drug. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the review has determined that the documentation does not support that a second series of Synvisc injections are medically reasonable or necessary for the enrollee. The documentation does not support that the Synvisc is safe and effective for the enrollee unless six months have lapsed between a series of injections. This request is for injections every four months, instead of every six months.  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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 27, 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 (99214) rendered by the out-of-network (OON) provider on August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic appliance (E0673) provided on January 20, 
2021.

You asked the Plan to pay for a pneumatic appliance. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare for prevention of deep vein thrombosis.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers.

The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for a pneumatic appliance (E0673) 
provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient office visit (99213) acupuncture, initial 15 minutes (97810) Acupuncture, each additional 15 minutes (97814) infrared light therapy (97026) therapeutic exercises (97110) Self-care/home management training (97535) vasopneumatic device (97016) provided August 16, 2021.  

You asked the Plan to pay for the acupuncturist service. You say that the denial says the services are not covered when billed by a chiropractor. The doctor is not a chiropractor, he's an acupuncturist and a doctor of Chinese medicine. The Plan denied your request. The Plan says these services are not covered under the Plan benefits.  

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.   

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the billed diagnoses of M79.621, M25.531, M25.571 and M79.601, do not support that the enrollee has chronic low back pain. Infrared therapy is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99213) acupuncture, initial 15 minutes (97810) Acupuncture, each additional 15 minutes (97814) infrared light therapy (97026) therapeutic exercises (97110) Self-care/home management training (97535) vasopneumatic device (97016) provided August 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided on August 17, 
2021.

You asked the Plan to waive the copayment for the cataract surgery. You say that the surgery did not work, and 
you will need to be seen again for a second surgery. You say that the $325 copayment should be reimbursed.
The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient surgery.
 
You have been asked to pay a $325 copayment for the cataract surgery. Cataract surgery falls within the 
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers" benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for cataract surgery provided 
on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on June 17, 2021
.  
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are included in the dialysis rate. The Plan denied your request. The Plan says the labs are not separately reportable.
  
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable.
       
We looked at the file and the rules. The records show the labs at issue were provided for the treatment of ESRD. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service coded 99053 provided on February 24, 2021.  You asked the Plan to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service.  We find that CPT code 99053 is not supported in the medical record. Specifically, this code has a status indicator of "B". This means that payment for this service is always bundled into payment for other services not specified and no separate payment can be made. Based on this information, we decided that Medicare rules for coverage of the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service have not been met. Therefore, we decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service coded 99053 provided on February 24, 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 care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have 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 daily skilled services are not necessary. Our physician reviewer found that you have stabilized medically and is ready for discharge from the hospital.  You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a lower level of care. Although further rehab 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. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near his baseline and you can receive services 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 admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on May 5, 2021.    

You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.  

The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.   

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a physician assistant, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Oncotype Dx genetic study.  You asked the Plan to pre-approve an Oncotype Dx genetic study. You say that the enrollee needs the Oncotype Dx genetic study in order to classify her risk of recurrence to determine if chemotherapy is necessary. The Plan denied your request. The Plan says the records show that the enrollee had bilateral mastectomy. The Plan says that genetic testing is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that.  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 an Oncotype Dx genetic study. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was diagnosed with Malignant neoplasm of upper-outer quadrant of right female breast status post right breast mastectomy with Sentinel Lymph NodeBiopsy (SLNB) complicated by postoperative bleeding warranting exploratory surgery on November 10, 2021. Her pathology report was significant for metastatic carcinoma positive for AE1/AE3 in additional lymph node "1B". On November 10, 2021, Stage 2B moderately differentiated infiltrating ductal carcinoma and DCIS intermediate grade solid and crib form was documented by her oncologist. Her care plan included Adjuvant radiation therapy to the axillary region for the extranodal invasion. Additionally, adjuvant endocrine therapy with an aromatase inhibitor (AI) was also recommended given that she was strongly positive for ER/PR. However, to check if she would benefit from adjuvant chemotherapy since she was found to have (+) LN involvement, a request for her surgical tissue to be sent for Oncotype was submitted. The review of the records showed that member had bilateral mastectomy. The request for genetic testing 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 an Oncotype Dx genetic study have not been met. Therefore, we decided that the Plan does not have to pre-approve an Oncotype Dx genetic study.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for FoundationOne testing (81455) provided on July 1, 2021.

You asked the Plan to pay for FoundationOne testing. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under code 
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be 
denied automatically as not medically necessary.

We looked at the file and Medicare rules. The testing at issue was submitted with 81455 and is unlikely to 
impact therapeutic decision-making in the clinical management of the patient. Based on this information, we 
decided that Medicare rules for coverage of FoundationOne testing have not been met. Therefore, we decided 
that the Plan does not have to pay for FoundationOne testing (81455) provided on July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752).  
You asked the Plan to pre-approve the spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752). You say that this procedure fills a treatment gap for patients that do not receive adequate relief from traditional methods. You say that the evidence supports this procedure is the primary treatment for low back pain and should be authorized. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered.  

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 spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy.
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752) have not been met. Therefore, we decided that the Plan does not have to pre-approve the spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic appliance (E0673) provided on April 9, 2021.

You asked the Plan to pay for a pneumatic appliance. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare for prevention of deep vein thrombosis.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers.

The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for a pneumatic appliance (E0673) 
provided on April 9, 2021.