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

 We decided that the Plan does not have to pre-approve left atrial appendage occlusion (the Watchman device) for the enrollee.  You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is covered if there is an inability to tolerate long-term oral anticoagulation therapy.  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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee does not wish to take Xarelto due to cost and warfarin due to testing requirements. The record does not contain a formal shared decision making interaction with an independent non-interventional physician as required by the criteria to support the recommendation. The elements of the coverage determination are not satisfied.  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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve left atrial appendage occlusion (the Watchman device) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on August 10, 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 domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an adjustable bed.  You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says no clinical information was received for this request.  The Plan must follow Medicare rules. Medicare rules say that durable medical equipment is covered when it has a primarily medical purpose.   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 bed. Our reviewer says that the requested bed is not considered medically reasonable and necessary in this case. Our physician reviewer found the provider has specifically requested an adjustable bed and not a hospital bed. An adjustable bed would not be covered as durable medical equipment, per Medicare guidelines.  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 bed have not been met. Therefore, we decided that the Plan does not have to pre-approve an adjustable bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient clinic services provided on September 28, 2021, by an OON provider.  You asked the Plan to pay for the OON outpatient clinic services. You say that the medical records provided support the medical necessity of the services provided. The Plan denied your request. The Plan says the OON services were not authorized.  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 outpatient clinic services provided on September 28, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 19, 2021.  You asked the Plan to pay for a comprehensive oral evaluation. You say that you were misinformed by the Plan and the dentist. You were told you would not have an out-of-pocket expense for this visit. You also say that you changed Plans in 2020 and your record should have been wiped clean and not added to your current Plan. The Plan should pay for this exam as you are on a low income and you cannot afford to pay this charge. The Plan denied your request. The Plan says the frequency limitation has been exceeded.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a comprehensive oral evaluation once every three years.   We looked at the file and Medicare rules. The records show you received a comprehensive oral evaluation on December 16, 2020; therefore, you have exhausted your maximum benefit for this service.    Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for home infusion therapy (99601) provided on May 5, 2021.  You asked the Plan to pay for home infusion therapy. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with a valid code.  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 find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601) provided on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a vest with a built-in heart pacing device and event recorder (LifeVest) provided from August 16, 2021, to September 16, 2021.  

You asked the Plan to waive the coinsurance for the LifeVest. You say that you were not aware of any coinsurance. The Plan denied your request. The Plan says the correct coinsurance 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% coinsurance for each advanced durable medical equipment (DME) item, including specialty brand items.     

You have been asked to pay $586.29, which is 20% of the allowed amount for the LifeVest ($2931.45 allowed amount x 20% coinsurance = $586.29). The LifeVest falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a vest with a built-in heart pacing device and event recorder (LifeVest) provided from August 16, 2021, to September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pain management services rendered on July 11, 2020.  You asked the Plan to pay for these services. You say that your facility has been forced to reduce manpower due to the pandemic. The Plan denied your request. The Plan says the claim was not filed timely.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for these services was not filed until October 6, 2021. A valid Waiver of Liability (WOL) was not received until October 12, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the pain management services rendered on July 11, 2020.
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 this is considered experimental and investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 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.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital discharge day management services billed with code 99239 and provided on April 26, 2021.  You asked the Plan to pay for the hospital discharge day management services. You say that the records provided support the services in dispute. The Plan denied your request. The Plan says the code in dispute remains not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that critical care is a time-based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided.  In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes.   We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation indicates that 25 minutes of time was spent on discharge services. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services billed with code 99239 have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services billed with code 99239 and provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplemental dental services provided on September 7, 2021.  

You asked the Plan to pay for the supplemental dental services. You say that you should not have to pay anything. The Plan denied your request. The Plan says your annual dental allowance maximum has been met.  

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. Specifically, you exceeded the Plan's allowed maximum of $2,000 for supplemental dental services and are responsible for the overage amount. Therefore, we decided that the Plan does not have to pay for the supplemental dental services provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA).  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that repeat RFA is covered when specific criteria are met.  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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic axial neck pain. He had cervical RFA in May of 2021 and had pain relief that decreased from eight to nine out of 10 to three to four out of 10. The pain relief lasted six weeks. The Medicare rules require a minimum of 50 percent pain relief for six months. The criteria are not met; therefore, repeat RFA is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoral periapical radiographic images (D0220 and D0230), provided on October 4, 2021.  

You asked the Plan to pay for the intraoral periapical radiographic images. You say that the services should be covered. The Plan denied your request. The Plan says these are not covered services.  

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. Specifically, these services are not listed in the Plan's benefit chart.        

Therefore, we decided that the Plan does not have to pay for the intraoral periapical radiographic images (D0220 and D0230), provided on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pathology services provided on August 19, 2021 by an out-of-network (OON) provider.  

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 were rendered by an out-of-network provider without prior authorization.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   

The 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 the pathology services provided on August 19, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 31, 2021, to August 5, 2021.  You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive skilled services on the dates of service in this case.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF care. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care have not been met. Specifically, the file shows that the enrollee did not receive skilled care on the dates of service in this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 31, 2021, to August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87798, 87801) provided on August 18, 2021.  

You asked the Plan to pay for laboratory services. You say that these services were performed. The Plan denied your request. The Plan says there is insufficient documentation to support these services.  

The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must be related to a patient's illness or injury (or symptom or complaint) and ordered by a physician.  

We looked at the file and Medicare rules. The submitted records do not include a physician order for the testing at issue or medical records showing that the tests were medically necessary. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87798, 87801) provided on August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a replacement lightweight manual wheelchair.  

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the notes do not indicate why a replacement is needed, nor why repairs cannot be made to the existing wheelchair.  

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 wheelchair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that it is medically necessary to obtain a new wheelchair rather than having the present wheelchair properly repaired. There is no documentation that the new wheelchair would meet the enrollee's needs better than the old one if the old one is properly repaired.   

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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement lightweight manual wheelchair.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on August 2, 2021.  

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility is not a Medicare covered benefit.  

The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination.   

The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection service provided on August 11, 2021.  

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code cannot be separately reimbursed.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  

The file shows that code 64415 was billed with an XE modifier. The medical records provided do not show that the service occurred during a separate encounter. 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 injection service provided on August 11, 2021.