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

We decided that the Plan does not have to pay for a walker received on May 14, 2021.

You asked the Plan to pay for the walker. You say that this should be paid for. The Plan denied your request. The Plan says the provider is not certified for Medicare.

The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. 

The rendering provider is not eligible to bill Medicare. The Plan did not pre-approve the walker. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that Medicare rules for coverage of the walker have not been met. Therefore, we decided that the Plan does not have to pay for a walker received on May 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on September 10, 2020 to July 26, 2021.

You asked the Plan to pay for psychotherapy services. You say that you do not receive marriage or family therapy from the provider at issue but only individual treatment. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue is not enrolled in the Medicare program.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided on September 10, 2020 to July 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance (CPT code
E0673) provided to the enrollee on October 22, 2020.
You asked the Plan to pay for the durable medical equipment (DME). You say that the claim should be paid.
The Plan denied your request. The Plan says this is not covered.
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 pneumatic compression device and/or supplies is not covered by Medicare to prevent deep vein thrombosis
during and/or following surgery, at home, or in any setting. The Plan states the enrollee used the equipment in
the facility during and/or after surgery. The Plan states payment for this service would have been included in the facility DRG or PPS prospective payment. intermittent limb compression. Therefore, we decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance (CPT code E0673) provided to the enrollee on October 22, 2020.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for vertebral corpectomies (63082). We decided that the Plan does not have to pay for the insertion of intervertebral biomechanical devices (22854).

You asked the Plan to pay for vertebral corpectomies (63082). You say that these codes are supported in the records. The Plan says that these codes are not documented.

We decided that the Plan has to pay for vertebral corpectomies (63082).

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

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 vertebral corpectomies (63082). Our reviewer says that this code is supported. Our physician reviewer found the operative report states "High -speed drill was then used to perform partial corpectomies of C5, 6, 7, and T1 respectively of approximately 50% of the vertebral body." 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of vertebral corpectomies (63082) have been met. Therefore, we decided that the Plan has to pay for vertebral corpectomies (63082).

We also decided that the Plan does not have to pay for the insertion of intervertebral biomechanical devices (22854).

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

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 insertion of intervertebral biomechanical devices (22854). Our reviewer says that this code is not supported. Our physician reviewer found the operative report does not include enough documentation to describe vertebral bodies were prepared for a biomechanical device, which is then secured with screws, wires or plates. 

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 insertion of intervertebral biomechanical devices (22854) have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of intervertebral biomechanical devices (22854).

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced knee/foot feature (L5850, L5981) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the request for K3 knee and foot does not meet Medicare criteria as being reasonable and necessary.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the medical records provided, there is no documentation that supports that the enrollee is a K3 level ambulator in order to indicate this request. The records document the enrollee requires a cane for ambulation which is not consistent with a K3 level. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with an advanced knee/foot feature (L5850, L5981) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nucala.

You asked the Plan to pre-approve Nucala. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nucala.

Benefits for Nucala 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there are not enough studies to show that this device will help in care.  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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (71045) provided August 9, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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, we have confirmed that code 71045 is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (71045) provided August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $30 copayment charged for physician services provided on March 19, 2021.
You asked the Plan to waive these services. You say that you thought the copayment would be $20. The Plan denied your request. The Plan says this copayment was charged based on the service provided and the Plan contract agreement.
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 $30 copayment for podiatrist services. 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 $30 copayment charged for physician services provided on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vascular study provided on July 6, 2021.

You asked the Plan to pay for the services provided. You say that this is not a bunded charge. The Plan denied your request. The Plan says an appropriate modifier was not billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

In this case, the CPT Code Manual definition of code 93976 is Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study. 

The file shows that that CPT code 93976 was billed with code 76857. We find that code 93976 may be eligible for payment when billed with this code pair. The claim provided does not include a modifier suitable for payment. 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 vascular study provided on July 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care (99220) electrocardiogram, routine ECG with at least 12 leads (93010x4) provided April 2, 2021 to April 7, 2021.

You asked the Plan to pay for the observation and electrocardiogram services. You say that resubmitting the claim with the medical record and prior denial. Please review the attached supporting documentation as the services have been deemed payable. The Plan denied your request. The Plan says the records was not provided or not provided timely or was insufficient/incomplete.

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 find that CPT codes 99220 and 93010 are not supported in the medical record. Specifically, the medical records was requested from the provider to support the billed service without success. Based on this information, we decided that Medicare rules for coverage of the observation and electrocardiogram services have not been met. Therefore, we decided that the Plan does not have to pay for initial observation care (99220) electrocardiogram, routine ECG with at least 12 leads (93010x4) provided April 2, 2021 to April 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Placement of amniotic membrane on the ocular surface (65778-59-RT) provided on April 29, 2021.

You asked the Plan to pay for code 65778-59-RT. You say that the medical records support the use of modifier -59 with the billing of code 65778 provided on April 29, 2021. The Plan denied your request. The Plan says the medical records do not support the use of modifier -59 with the billing of code 65778 provided on April 29, 2021.

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. 

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 code 65778-59-RT Our reviewer says that the medical records do not support the use of modifier -59 with the billing of code 65778 provided on April 29, 2021. Our physician reviewer found the provided records are insufficient to establish that the requested service is a distinct procedural service from the other service simultaneously billed.

The elements of the coverage rules are not satisfied. The requested service cannot be 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 code 65778-59-RT have not been met. Therefore, we decided that the Plan does not have to pay for the Placement of amniotic membrane on the ocular surface (65778-59-RT) provided on April 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate.

You asked the Plan to pre-approve Methotrexate. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methotrexate.

Benefits for Methotrexate 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 dental services provided on August 6, 2021.

You asked the Plan to pay for dental services. You say that your insurance sales agent informed you of a $2,000 dental allowance, not a $1,000 allowance. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the Plan has covered the $1,000 benefit allowance for dental services, so you are responsible for any amount over this.

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 covers a $1,000 combined allowance for supplemental dental benefits. 

We looked at the file, the Plan's rules, and Medicare rules. The Plan has paid the full $1,000 allowance for dental benefits; therefore, you are responsible for any amount beyond this.

Therefore, we decided that the Plan does not have to pay for dental services provided on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive or reduce the $122.58 cost share applied to the deductible for services provided on June 24, 2021.  

You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this service applied to the deductible correctly. 

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $150 deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is deductible which applies to some services provided. This cost sharing is a contractual obligation that had not been met at the time this service was received. Therefore, we decided that the Plan does not have to waive the $122.58 cost share applied to the deductible for services provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injections (64494) provided on April 27, 2021.  

You asked the Plan to pay for code 64494. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  

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 code 64494 have not been met. Therefore, we decided that the Plan does not have to pay for the injections (64494) provided on April 27, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography (CT) scan and magnetic resonance imaging (MRI) of the shoulder.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the doctor must provide sufficient evidence that the scans are reasonable and necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs and CT scans are covered 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 the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the MRI makes sense to evaluate the various muscles and tendons of the left shoulder. Since there is severe degenerative joint disease of the glenohumeral joint the planned total joint replacement makes complete sense and the CT is necessary for prosthesis planning. 

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 services have been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) scan and magnetic resonance imaging (MRI) of the shoulder.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no indication of at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have bilateral pedal edema with hyperkeratotic toes. There is no documentation of truncal edema. The enrollee is noted to have tried compression garments, exercise and elevation. There is no evidence that the enrollee has used a basic pump device (E0651) for four weeks, resulting in treatment failure or intolerance. Therefore, the documentation does not support that an advanced leg pump (E0652) is currently medically necessary or reasonable. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.