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

 We decided that the Plan does not have to pay for the surgical services rendered on September 9, 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 procedure code 24301 is 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.  In this case, the CPT Code Manual definition of code 24301 is muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331).  We find that CPT code 24301 is not supported in the medical record. Specifically, there is no documentation of a muscle or tendon transfer of the upper arm or elbow. 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 pay for the surgical services rendered on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214-25) provided on September 15, 2021.  You asked the Plan to pay for the office visit. 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 providers must report services correctly.  We find that CPT code 99214-25 is not supported in the medical record. The office visit at issue was billed with modifier 25, which is used to report a significant, separately identifiable Evaluation and Management (EM) service by the same physician or other qualified health care professional on the same day of a procedure or other service. There is no documentation of any significant, separately identifiable evaluation unrelated to the treatment provided to the enrollee on this date of service. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99214-25) provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injections (62320) provided on October 4, 2021.  You asked the Plan to pay for code 62320. 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.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.     We looked at the file and Medicare rules. In this case, there were no medical records provided to verify if the services were billed appropriately per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the injections (62320) provided on October 4, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the laboratory services provided on April 21, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.  The enrollee was referred for the laboratory services by a contract provider. The file does not show that the plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the laboratory services provided on April 21, 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: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy (90837) provided on February 10, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for psychotherapy. You say that you have rendered treatment to the patient in good faith that the service will get reimbursed. You also say that the service was provided with no adequate time frame to obtain authorization for the service. The Plan denied your request. The Plan says the claim was denied due to no prior authorization for this date of service, and they did not authorize any services for this provider. The Plan also says that the rendering provider is a non-participating provider and there is no referring provider involved in these services.  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 psychotherapy (90837) provided on February 10, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 4, 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 rendered are not a covered benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  Review of the file shows that the enrollee has metastatic breast cancer. The enrollee does not have a specific condition that would meet criteria for the services rendered. This means that the laboratory services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional features for a leg prosthetic (L5930).  You asked the Plan to pre-approve the features. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not level 4 ambulator.  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 features. 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 supports a K4 level ambulator. The records indicate that you have been using crutches or a walker after your amputation procedure and your orthopedist on 12/07/2021 indicate you appear to be at a K3 level for ambulation.   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 features have not been met. Therefore, we decided that the Plan does not have to pre-approve additional features for a leg prosthetic (L5930).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an orthopedic consultation (99245, 73560, 73590) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an orthopedic consultation. You say that you saw this provider in the past and he corrected the mistakes of an in-network surgeon. The Plan denied your request. The Plan says there are in-network providers available for the requested service.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an orthopedic consultation (99245, 73560, 73590) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Travel allowance (P9604) provided on January 29, 2021.  You asked the Plan to pay for code P9604. 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.  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 P9604 is Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated trip charge.  We find that CPT code P9604 is not supported in the medical record. Specifically, the records do not provide enough information to verify if the code was billed correctly per Medicare guidelines. Based on this information, we decided that Medicare rules for coverage of code P9604 have not been met. Therefore, we decided that the Plan does not have to pay for the Travel allowance (P9604) provided on January 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gelsyn-3.  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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee osteoarthritis with pain described as mild to occasionally moderate achiness/pain, worse with activity and ambulation. She rates her pain at six out of 10 after receiving the injections. There is no documentation of conservative therapy consisting of non-pharmacologic therapy or simple analgesics/non-steroidal anti-inflammatory drugs (NSAIDs) that have been tried for three months and failed. It is unknown if she has an effusion to see if aspiration would be beneficial. After repeat injections, ,there is no documentation of significant reduction in the doses of NSAIDs taken or intra-articular steroid injections to the knees during the six-month period following the injection. GelSyn-3 is therefore 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 Gelsyn-3.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Infectious agent detection (87631) provided on January 28, 2021.  You asked the Plan to pay for code 87631. 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 providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 87631 is Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.  We find that CPT code 87631 is not supported in the medical record. Specifically, the records show that more than five targets were tested and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of code 87631 have not been met. Therefore, we decided that the Plan does not have to pay for the Infectious agent detection (87631) provided on January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for eyeglasses provided on September 14, 2021.  You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says the claim processed correctly and the benefit of $150 was applied to the member's purchase.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the Plan processed the claim correctly and the eyewear benefit of $150 was applied to your purchase. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit rendered on August 4, 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 were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 23 for an emergency room setting; however, the file shows that the services were obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the office visit rendered on August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a vacuum erection device.  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 not a covered benefit.  The Plan must follow Medicare rules. The rules say that vacuum erection devices (L7900) are statutorily not covered.  The requested device is statutorily not covered by Medicare. 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 vacuum erection device.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve positron emission tomography (PET) and computed tomography (CT) of the brain.  You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that research studies have found a lack of proof/evidence that routine use of this study would improve the outcome for memory problems.  The Plan must follow Medicare rules. Medicare rules say that PET scans and CT scan are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested imaging is medically reasonable and necessary. Our physician reviewer found the enrollee has cognitive decline. The Montreal Cognitive Assessment (MoCA) score is 22/30, documenting this decline. Differential diagnoses include Alzheimer's disease vs Frontotemporal Dementia which qualifies as a covered indication for PET/CT.  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 scan have been met. Therefore, we decided that the Plan has to pre-approve positron emission tomography (PET) and computed tomography (CT) of the brain.   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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray provided on September 14, 2021  You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $10 copayment for Outpatient diagnostic tests and therapeutic services and supplies.         You have been asked to pay a $10 copayment for an x-ray. X-rays fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an x-ray provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary visit provided on July 13, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary visit. You say that the provider relies on the facility staff to verify eligibility and obtain authorization. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on July 13, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the annual wellness visit (G0438) provided on October 1, 2021.  You asked the Plan to pay for the annual wellness visit (G0438). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that you have exhausted this benefit.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan is denying payment for the annual wellness visit (G0438) you received on October 1, 2021, because the Plan says that you have exhausted this benefit for the year. The Plan states that you received an annual wellness visit on June 26, 2021, that was paid for by the Plan and that you are only covered for one annual wellness visit every 12 months. However, the Plan has only provided a claim that was paid for date of service June 26, 2021, with code 99214. Code 99214 is not an annual wellness visit code. The Plan has not shown that you have had more than one annual wellness visit to deny payment for the annual wellness visit (G0438) provided on October 1, 2021. Therefore, we decided that the Plan has to pay for the annual wellness visit (G0438) provided on October 1, 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) transfer.  You asked the Plan to pre-approve the transfer. The Plan denied your request. The Plan says this is not medically 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 transfer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He was treated for pain. His lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy. The enrollee was at a contact guard assist level for functional mobility including gait to 200 feet with a rolling walker. The enrollee required varying assist with activities of daily living. It is not medically reasonable or necessary to transfer to an alternative SNF.      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 transfer have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) transfer.