Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283) and manual therapy techniques (97140) provided from March 05, 2021, to March 31, 2021.
You asked the Plan to pay for electrical stimulation (G0283) and manual therapy techniques (97140). You say that the Plan should pay this claim. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for electrical stimulation (G0283) and manual therapy techniques (97140) provided from March 05, 2021, to March 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services for shoulder surgery coded as
29806 provided March 29, 2021.

You asked the Plan to pay for the assistant surgeon services for shoulder surgery. You say that you would like
this claim reprocessed and approved for payment. The Plan denied your request. The Plan says services of an
assistant surgeon, co-surgeon, or surgical team are not covered for this procedure.

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, you billed assistant surgery services for code 29806. The Medicare Fee Schedule Database
contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant
surgeon is not medically necessary and will not be paid. Based on this information, we decided that Medicare
rules for coverage of the assistant surgeon services for shoulder surgery have not been met. Therefore, we
decided that the Plan does not have to pay for the assistant surgeon services for shoulder surgery coded as
29806 provided March 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for abdominal ultrasound coded as 76705 provided on May 27,
2021.
You asked the Plan to pay for abdominal ultrasound. You say that you would like this claim reprocessed for
medical necessity. The Plan denied your request. The Plan says this claim was not billed with an appropriate
modifier as required by Medicare rules.
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 76705
has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for abdominal ultrasound coded as 76705 provided on May 27, 2021
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on March 22,
2021.
You asked the Plan to pay for psychotherapy services. You say that these medically necessary services were
provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment for
psychotherapy services have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's
attending or primary care physician.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of psychotherapy services have not been met. Specifically, there is no documentation in the provided
medical records of an attempt to consult with the enrollee's attending or primary care physician. Therefore, we
decided that the Plan does not have to pay for psychotherapy services (90832) provided on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulation treatment (98941x4) and
electrical stimulation (G0283).
You asked the Plan to pre-approve the chiropractic services. You say that the enrollee comes to your office due
to spinal subluxations that have been documented. The chronic pain from her subluxations is relieved by
chiropractic treatment. The Plan denied your request. The Plan says electrical stimulation is not covered under
Medicare. 2 chiropractic visits
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
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 chiropractic services.
Our reviewer says that the coverage criteria for the chiropractic services were met. Our physician reviewer
found in this case, the record indicates that the enrollee had cervical pain with subluxation and continues to
have fibromyalgia. The record does not indicate that the enrollee is expected to have improvement. The record
indicates that the requested service is maintenance therapy. The elements of the coverage criteria are not
satisfied, and the requested service is not recommended.
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 chiropractic services have not been met. Therefore, we decided that the Plan
does not have to pre-approve chiropractic manipulation treatment (98941x4) and electrical stimulation
(G0283)
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine, non-emergency transportation trips.

You asked the Plan to provide coverage for additional routine, non-emergency transportation trips. You say that you cannot drive due to a disabling medical conditions, and you do not have family members or government resources to assist you to get to your medical appointments. The Plan denied your request. The Plan says you have exhausted all 24 one-way trips.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine, non-emergency transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 10,
2021.

You asked the Plan to pay for the limited evaluation. You say that you had to go back to the dentist only a few
days after your cleaning because your tooth broke unexpectedly. This service was necessary. The Plan denied
your request. The Plan says you had a previous limited oral exam on January 7, 2021, which was covered by
the Plan. Only one limited oral exam can be provided per plan year. Therefore, the exam provided on May 10,
2021, exceeds the frequency allowed by your benefit and will not be covered.

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. The Plan can cover one
limited exam to evaluate a problem (D0140) per plan year.

Though the Plan offers a dental benefit in excess of Medicare coverage, the limited exam is requested in a
frequency that exceeds what is covered under this benefit. Documentation shows that the Plan covered a
previous limited exam in January 2021. Therefore, we decided that the Plan does not have to pay for the limited
oral evaluation (D0140) provided on May 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided on April 22 to April 30, 2021.
You asked the Plan to waive the copayment for SNF care. You say that you were told more than once that you would not have to pay anything. The Plan denied your request. The Plan says the correct copayment was applied.
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 copayment for each day for days 1 to 20 for a stay at a SNF. You have been asked to pay $180, or a $20 copayment for each day of a 9-day stay, for SNF care. SNF care falls within the "Skilled nursing facility (SNF) care" 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 SNF care provided on April 22 to April 30, 2021.
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibilities from representatives of the SNF is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive eye examination (92004) prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation (92310) provided May 26,2021.
You asked the Plan to pay for the vision services. You say that your eyes changed enough that your contacts needed updated. The doctor needed to give you an eye exam to verify the change because of the length of time since your last exam. The Plan denied your request. The Plan says routine eye exams are limited to one exam every 12 months.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine eye exams once every 12 months. We looked at the file and the Plan's rules. routine eye exams are limited to one exam every 12 months. The records show this benefit was already used on date of service April 14, 2021. Therefore, this benefit is not available until April 14, 2022. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive eye examination (92004) prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation (92310) provided May 26,2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 8, 2020.
You asked the Plan to pay for drug testing. You say that physicians send specimens to your lab for testing and you do not have any access to physician notes and reports. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim.
Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on December 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time over and
above those usually included in an office visit or other non-facility service(s), when performed during a Public
Health Emergency as defined by law, due to respiratory-transmitted infectious disease (99072) provided from
March 26, 2021, through April 2, 2021.

You asked the Plan to pay for additional supplies, materials, and clinical staff time. You say that that
precautions were taken by the provider of the service prior to treating the patient. The Plan denied your request.
The Plan says CMS considers these services bundled with the services provided to the enrollee on the same
dates of service and is therefore not eligible for separate reimbursement.

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 for
additional supplies, materials, and clinical staff time has a bundled relationship with code 99072 and cannot be
paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing
criteria have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies,
materials, and clinical staff time over and above those usually included in an office visit or other non-facility
service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted
infectious disease (99072) provided from March 26, 2021, through April 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0673 and E0675),
provided on March 26, 2021.
You asked the Plan to pre-approve a pneumatic compression device. You say that the item was medically
necessary. The Plan denied your request. The Plan says the enrollee used the equipment in the facility during
and/or after surgery.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that a pneumatic compression device is being requested for use in a SNF or hospital. Therefore,
we decided that the Plan does not have to pre-approve a pneumatic compression device (E0673 and E0675),
provided on March 26, 2021.
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. You say that the enrollee requires IRF care. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.

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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on February
12, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was no
documentation of a consultation with the attending or primary care physician.
The Plan must follow Medicare rules. Medicare rules say that if the patient assents to the consultation, the CP
must attempt to consult with the patient's physician within a reasonable time after receiving the consent. If the
CP's attempts to consult directly with the physician are not successful, the CP must notify the physician within
a reasonable time that he or she is furnishing services to the patient.
We looked at the file and Medicare rules. In this case, the CP has not documented, in the enrollee's medical
record, that contact was made with the PCP or attending, nor does the claim list a referring/ordering provider.
Based on this information, we decided that Medicare rules for coverage of the services have not been met.
Therefore, we decided that the Plan does not have to pay for the outpatient mental health services provided on
February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 low air loss mattress.
You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of multiple stage 2 or higher ulcers on the trunk or pelvis.
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 mattress. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal objective evidence of multiple stage II pressure ulcers located on the trunk or pelvis, which have been treated in a comprehensive program. There is no evidence on an objective physical exam of large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis. There is also no evidence that you have a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. 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 mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 low air loss mattress.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services rendered on January 12, 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 that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion services rendered on January 12, 2021.
Benefits for these services 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140)
provided on May 26, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you have an infected
tooth that they will not pull until the balance is paid. The Plan denied your request. The Plan says you have
exceeded the Plan's frequency maximum.

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, problem focused limited oral
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem
focused limited oral evaluation (D0140) on March 31, 2021 and your problem focused limited oral evaluation
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem
focused limited oral evaluation (D0140) provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation
provided on April 29, 2021 by an out-of-network provider.
You asked the Plan to pay for transtelephonic rhythm strip pacemaker evaluation (93293). You say that the
services were medically necessary. The Plan denied your request. The Plan says the services were not urgent or
emergent nor 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 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 the service. Therefore, we decided that
the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation provided on April 29,
2021 by an out-of-network provider