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

We decided that the Plan does not have to pre-approve a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715) and administration (90741) provided on June 9, 2020.
You asked the Plan to pre-approve a Tdap vaccine and administration. You say that you should not have received this notification. The Plan denied your request. The Plan says this processed correctly.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Tdap vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a Tdap vaccine and administration. Therefore, we decided that the Plan does not have to pre-approve a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715) and administration (90741) provided on June 9, 2020.
Benefits for a Tdap vaccine and administration 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on February 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the surgery services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 surgery services provided on February 10, 2021 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device (L8702).
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is not medically 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 a MyoPro orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that, at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy, including constraint induced movement therapy, conventional muscle strengthening, and Botox for spasticity if needed. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for the
enrollee, improve hemiparetic arm function, or be safe for long-term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MyoPro orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device (L8702).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided January 5, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed services. 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 G0483 is not supported in the medical record. Specifically, the place of service listed on
the claim form (81, laboratory) does not match the place of service described in the records (11, office setting).
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction of lower or sacral spinal facet joint nerves
with imaging guidance.

You asked the Plan to pre-approve destruction of lower or sacral spinal facet joint nerves with imaging
guidance. You say that the services are necessary. The Plan denied your request. The Plan says based on the
documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are
allowed per session per spine region.

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 destruction of lower or sacral spinal
facet joint nerves with imaging guidance. Our reviewer says that the services are not medically necessary. Our
physician reviewer found in this case there is a lack of clinical evidence provided to explain the need for a three
or four-level procedure bilaterally may be considered under unique circumstances.

For a three or four-level procedure bilaterally may be considered under unique circumstances and with
sufficient documentation of medical necessity on appeal. There is nothing in the medical records provided to
explain why an exception should be made for the excessive level above the allowable amount. It is noted that
the member has recently undergone L2-3 medial branch blocks with clinically significant pain relief. Medicare
states that only one or two levels, either unilateral or bilateral, are allowed per session per spine region. The
need for a three or four-level procedure bilaterally may be considered under unique circumstances and with
sufficient documentation of medical necessity on appeal. The review has determined that the coverage criteria
in the LCD have not been met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of destruction of lower or sacral spinal facet joint nerves with imaging guidance
have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction of lower or
sacral spinal facet joint nerves with imaging guidance.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a genetic cancer screening (81201, 81317, 81405, 81408) provided on March 11, 2021.
You asked the Plan to pay for a genetic cancer screening. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. As Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX, and it is a test not currently satisfactorily described by any existing CPT code. Therefore, to report a CGP service, test providers should use CPT code 81479 at this time. We find that CPT codes 81201, 81317, 81405, and 81408 are not supported in the medical record. Specifically, these codes were used to report a CGP service, which should be reported with 81479. Based on this information, we decided that Medicare rules for coverage of a genetic cancer screening have not been met. Therefore, we decided that the Plan does not have to pay for a genetic cancer screening (81201, 81317, 81405, 81408) provided on March 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 home health skilled nursing visits.

You asked the Plan to pre-approve 6 home health skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 6 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The latest records available from September 9, 2021 report the enrollee is in a stable condition. In short, no acute skilled nursing needs are documented in the available records to justify the six additional skilled nursing visits requested.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99203) provided on March 15, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 services 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 these services. Therefore, we decided that the Plan does not have to pay for physician services (99203) provided on March 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the two foot x-rays you had on May 13, 2021.
You asked the Plan to waive the copayments for the x-rays. You say that you went to the doctor because you had toe discomfort. You said that you did not request the x-rays and were not advised you would be charged for the x-rays. The Plan denied your request. The Plan says you were charged these copayments 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 $10 copayment for x-rays. You have been asked to pay a $10 copayment for each of the x-rays. These copayments apply regardless of the reason for the x-rays. 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 copayments for the two foot x-rays you had on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care rendered on August 6, 2020.
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 claim was not billed with a valid primary diagnosis code.
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 claim was not billed with a valid primary diagnosis code. Therefore, we decided that the Plan does not have to pay for the nursing facility care rendered on August 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services from May 5, 2021, through May 12, 2021, and from May 16, 2021, through May 20, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stays. You say that you don't feel you should have to pay separate copayments. The Plan denied your request. The Plan says the copayments were applied 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 $295 copayment per admission for each medically necessary inpatient stay.
You have been asked to pay a total of $590 ($295 copayment x 2 inpatient admissions = $590) for the inpatient hospital stays. These services fall within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital services from May 5, 2021, through May 12, 2021, and from May 16, 2021, through May 20, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on October 27, 2020 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 rest home visit provided on October 27, 2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided you do not require the intensity of services provided at an IRF.
Specifically, the you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 16, 2020 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 office visit provided on September 16, 2020 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 chiropractic services rendered on April 14, 2021.
You asked the Plan to pay for these services. You say that you thought you would only have to pay a copayment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The file shows that the chiropractor submitted a claim for procedure codes 99202 (office visit), G8539 (functional outcome assessment), and G8942 (functional outcome assessment). These services are not covered when performed by a chiropractor. Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered on April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the hospital bed provided on April 12, 2021 and May 12, 2021.
You asked the Plan to waive the coinsurance for the hospital bed. You say that you were never told you would have to pay $15.52 to rent the hospital bed every month. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 20% coinsurance for out-of-network Medicare-covered durable medical equipment and related supplies. You have been asked to pay $15.52 which is 20% of the allowed amount for the hospital bed on each date of service. The allowed amount is $77.62. ($77.62 x 20% = $15.52). The hospital bed 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 the hospital bed provided on April 12, 2021 and May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204), drainage (28002), and ultrasounds
(93922, 93925) provided on March 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit, drainage, and ultrasounds. You say that your records show that
this provider is a plan provider. The Plan denied your request. The Plan says this provider is out-of-network
and these 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 an office visit (99204), drainage (28002), and
ultrasounds (93922, 93925) provided on March 3, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient knee manipulation procedure you had on March 8, 2021.
You asked the Plan to waive the copayment for the outpatient knee procedure. You say that it was a lower cost when you actually had your full knee replacement. The Plan denied your request. The Plan says you were charged this copayment 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 $400 copayment for outpatient surgery.
You have been asked to pay a $400 copayment for the outpatient knee procedure. The outpatient knee procedure falls within the outpatient surgery 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 outpatient knee manipulation procedure you had on March 8, 2021.