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

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a device coded as E0652 used to treat lymphedema that does not extend to chest, trunk, or abdomen is not eligible for reimbursement.
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 examinations have documented either no edema or trace edema in the left lower leg. You do have what is described as a popliteal cyst on the left but it does not appear that this has been evaluated by an orthopedic surgeon. There is no documentation of significant lymphedema and no documentation of abdominal or truncal edema. There is documentation that you have undergone sclerotherapy of the left great saphenous vein and that there are no further venous interventions required on the leg. The language in the referral to Tactile is not matched by the exam findings and the source documentation. There is no documentation of unique features of your condition that would necessitate a high-level lymphedema pump, and there is no evidence that lymphedema treatment was even considered or attempted with a lesser pump. 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 (E0652, E0667).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 26, 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 testing is not covered.
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. The test at issue in this appeal, FISH testing, was 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 rendered on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D7460) provided February 2, 2021.
You asked the Plan to pay for the dental services. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says the services at issued are not covered under your dental benefit.
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. Therefore, we decided that the Plan does not have to pay for dental services (D7460) provided February 2, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lab services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve lab services to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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
lab services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on June 28, 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 99205 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 99205 is Outpatient visit for evaluation and management of new patient, including medically appropriate examination and high level of medical decision making, total time 60-74.

We find that CPT code 99205 is not supported in the medical record. Specifically, the file shows that the enrollee was previously seen by a provider within the same practice on May 11, 2021; therefore, a new patient office visit does not apply. 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 office visit rendered on June 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care visits.
You asked the Plan to pre-approve home health care. You say that you are not getting the treatment you need to keep your arm and leg where you can use them. The Plan denied your request. The Plan says the denial of authorization for home health care is correct.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health care. Our reviewer says that you do not meet the Medicare criteria for the requested home health care. Our physician reviewer found the documentation does not support that you require skilled nursing services or skilled rehabilitation services to provide treatment that is medically necessary. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health care visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D5650, D0330, D9999) provided March 25, 2021 to March 31, 2021.
You asked the Plan to pay for the dental services. You say that the services were medically necessary and should be paid. The Plan denied your request. The Plan says the provider has opted out of the Medicare program and is not eligible for payment
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental services (D5650, D0330, D9999) provided March 25, 2021 to March 31, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on January 13, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first for review.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on June 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 the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the services were not billed with a valid primary diagnosis code. 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 initial hospital care rendered on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 7, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided to the enrollee on July 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (99601, 99602) provided April 16,
2021.
You asked the Plan to pay for the home health services. You say that the services were medically necessary.
The Plan denied your request. The Plan says this code billed is not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 99601 and 99602 is not supported in the medical record. Specifically, per the National
Physician Fee Schedule, these codes have a status of "I" and are not valid for Medicare payment. Based on this
information, we decided that Medicare rules for coverage of the home health services have not been met.
Therefore, we decided that the Plan does not have to pay for home health services (99601, 99602) provided
April 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601 and 99602 provided on May 19, 2021.
You asked the Plan to pay for the home infusion/specialty drug administration services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 99601 and 99602 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services.
Based on this information, we decided that Medicare rules for coverage of the home infusion/specialty drug administration services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601 and 99602 provided on May 19, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 6, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like reconsideration because you have not seen a dentist since 2020 and that dentist retired. The Plan denied your request. The Plan says this service is only allowed once every 36 months.
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 comprehensive oral evaluation does not meet criteria for coverage. Specifically, the record indicates that you previously received a comprehensive oral evaluation on January 15, 2020. Comprehensive oral evaluations are covered once every 36 months. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve the 10 additional physical therapy visits. You say that you would like reconsideration because you are still in pain and require additional physical therapy. The Plan denied your request. The Plan says the notes do not show that you need the ongoing skills of a physical therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 10 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found further skilled therapy at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. 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 10 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits
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 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 pre-approve the magnetic resonance imaging (MRI) spinal canal and contents (72148).
You asked the Plan to pre-approve MRI scan. You say that the enrollee underwent an x-ray of the LS spine and it is recommended to get an MRI of the LS spine for better evaluation. The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria for the requested MRI.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no neurological exam in the records and no documentation of medical necessity for an MRI. In fact, following the x-rays there is a note saying the enrollee was improving. Absent is a red flag such as abnormal reflexes or weakness etc. The presence of facet arthrosis on x-rays is not a valid indication for an MRI absent of a positive neurological exam. The medical necessity of MRI has not been established. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) spinal canal and contents (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services received on June 30, 2021.
You asked the Plan to pay for the services. You say that you were under the impression that your dental plan was going to cover 50% of the total claim. The Plan denied your request. The Plan says you are responsible for the difference in the provider's submitted fees and the allowed amounts for these 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. The Plan covers dental services as long as the provider has not opted out of Medicare.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for dental services received on June 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.
You asked the Plan to pre-approve the requested services. You say that the enrollee's condition has impacted his quality of life. The Plan denied your request. The Plan says there is a lack of evidence to support the device as safe and effective.
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 requested services. Our physician reviewer found that the interspinous process stabilization devices remain experimental in spinal surgery. More research is needed to show safety and efficacy. Therefore, the requested services are not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
You asked the Plan to pre-approve 12 additional physical therapy visits. You say that the services are medically necessary. 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 medically necessary outpatient therapy.
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 12 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found you have had twenty-four physical therapy treatments for the left shoulder condition thus far; the provided records do not clarify why your already established home exercise program and your previous treatments are inadequate to treat your condition. The records do not demonstrate that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. The record does not show that these services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiac catheterization procedure you
had at an outpatient hospital facility on July 16, 2021.
You asked the Plan to waive the copayment for the cardiac catheterization procedure. You say that you were
not told how much this would cost before the procedure. The Plan denied your request. The Plan says this
copayment was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for surgery at an outpatient hospital facility.
You have been asked to pay a $250 copayment for the cardiac catheterization procedure. The cardiac
catheterization procedure falls within the surgery at an outpatient hospital facility 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 the cardiac catheterization procedure you had at an outpatient
hospital facility on July 16, 2021.