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

We decided that the Plan does not have to pay for the oral function therapy provided on October 31, 2019.

You asked the Plan to pay for the services provided. You say that the documentation supports the services. The Plan denied your request. The Plan says the rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 92526 is 1. The MAI value for this code is 2. You billed 4 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the oral function therapy provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia provided on December 9, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the anesthesia. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim originally denied for not meeting coding standards, but 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 anesthesia provided on December 9, 2020 by an out-ofnetwork
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for manual therapy techniques provided on September 
1, 2020, October 28, 2020 and November 6, 2020. 
 
You asked the Plan to reimburse you for manual therapy techniques (97140). You say that you would like the 
Plan to reimburse you. The Plan denied your request. The Plan says coverage is limited to chiropractic 
manipulative therapy. 
 
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. Therefore, we decided that 
the Plan does not have to reimburse you for manual therapy techniques (97140) provided on September 1, 
2020, October 28, 2020 and November 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoe inserts (L3020), provided on May 6, 2021.

You asked the Plan to pay for shoe inserts. You say that the item was medically necessary. The Plan denied
your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for shoe inserts (L3020), provided on May
6, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says it is not
likely that more home visits are needed.
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.
The file shows that 5 home health skilled nursing visits were requested. The Plan has agreed to pre-approve 2
visits. 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 additional requested services.
Our physician reviewer found that there are no provider records, orders or nursing records that have been
submitted. Consequently, there is no documentation of skilled nursing needs. Therefore, the requested services
are not shown to be medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve home health skilled nursing services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee has issues 
with shortness of breath, heart disease, and arthritis. You say that the enrollee has no family to help her. You 
say that the enrollee has to get back and forth from her primary care doctors, laboratory, cardiologist, 
pharmacy, and other specialists. The Plan denied your request. The Plan says the requested number of 
transportation services exceeds the limit listed by the Plan. 

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way routine transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that the enrollee 
received coverage for 60 one-way routine transportation trips in the 2021 calendar year. Based on this 
information, we decided that you have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the LifeVest wearable cardioverter defibrillator you received on April 24, 2021.

You asked the Plan to waive the coinsurance for the LifeVest. You say that the Plan should cover this item in full because it was a mandatory part of your hospital protocol. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment. 

You have been asked to pay 20% coinsurance for the LifeVest. The LifeVest falls within the durable medical equipment benefit category.

This cost sharing applies regardless of the reason why you were provided with this device. 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 LifeVest wearable cardioverter defibrillator you received on April 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira 40/0.4ml injection (CPT code J0135), for the enrollee.

You asked the Plan to pre-approve the medication. You say that the enrollee's rheumatoid arthritis is under good control with the Humira. The Plan denied your request. The Plan says this medication falls under Part D coverage, but the enrollee has no Part D pharmacy benefit. The Plan states this medication does not fall under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Humira 40/0.4ml injection (CPT code J0135), for the enrollee.

Benefits for the medication 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound coded 76705 provided on May 24, 2021.

You asked the Plan to pay for the ultrasound. 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 separately 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. In this case, we have confirmed that code 76705 for the ultrasound has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound coded 76705 provided on May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for urine protein-to-creatinine ratio (PCR) panel testing provided on September 15, 2020.

You asked the Plan to pay for urine PCR panel. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because PCR testing is considered unproven and the standard of care is urinalysis with urine culture and sensitivity.

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 pay for urine PCR panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the standard of care for the evaluation of urinary incontinence is urinalysis and urine culture. The PCR testing is considered unproven and not 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 urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for urine protein-to-creatinine ratio (PCR) panel testing provided on September 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70450) provided May 22, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed and
is not eligible for separate payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450
has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for radiology services (70450) provided May 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation therapy provided on April 8, 2021.
You asked the Plan to pay for the electrical stimulation therapy. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
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 97014 is application of a modality to 1 or more areas; electrical stimulation (unattended). We find that CPT code 97014 is not supported in the medical record. Specifically, CPT code 97014 has a status indicator of I. This means that CPT code 97014 is not valid for Medicare billing purposes.
Based on this information, we decided that Medicare rules for coverage of the electrical stimulation therapy have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulation therapy provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided June 29, 2021.

You asked the Plan to pay for the eye refraction. You say that the eye refraction test should be covered because eye exams are covered after cataract surgery. The Plan denied your request. The Plan says you do not have routine vision benefits and this service is not covered under Medicare.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. 

The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) provided June 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the compounded drug provided on February 8, 2021.
You asked the Plan to pay for the compounded drug. You say that you attached the invoice for the compound
drug code J7999, and payment should be reconsidered. The Plan denied your request. The Plan says the billed
service 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 J7999 is compounded drug, not otherwise classified.
We asked our coder 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 compounded drug. Our reviewer says that the documentation submitted was reviewed and does not meet criteria for coverage. Our reviewer found that although Phenol is an Organic Compound, diluting with water is not considered a compound drug per the Food and Drug Administration. Our reviewer says that J3490, unclassified drugs, should be reported for this service.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the compounded drug billed have not been met. Therefore, we decided that the Plan does not have to pay for the compounded drug provided on February 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on February 12, 2021.
You asked the Plan to waive the copayment for the ambulance ride. You say that you do not feel as though the enrollee should be responsible for the $250 charge. You say the Plan should cover the ambulance ride. 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 a $250 copayment per one-way trip by ground or air ambulance.
You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. The record shows the ambulance ride is a covered service. 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 ambulance ride provided on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 30, 2020.
You asked the Plan to pay for out of network services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you 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 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 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 physician services provided on November 30, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the total knee arthroplasty (27447) rendered by the OON
provider on April 27, 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 total knee arthroplasty (27447) rendered by the OON provider on April 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided the enrollee appears to be generally not stable enough for transfer at this time. Acute care services can be safely administered at the current facility for the time being until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee
does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve mandibular partial denture. You say that you already have a waiver for 
approval of this service. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because this service is not covered by the Plan's dental benefits. 
 
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 pre-approve a 
mandibular partial denture (D5226).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428-NH, A0428-HN) and ground mileage (A0425-NH, A0425-HN) provided on February 26, 2021.
You asked the Plan to pay for the transportation services. You say that the transportation was medically necessary. The Plan denied your request. The Plan says the non-emergency transportation services are not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 transportation services. Our reviewer says that the transportation services are not medically necessary. Our physician reviewer found the provided documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated for the enrollee on February 26, 2021. The reviewer found the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on February 26, 2021. The reviewer also found that the documentation does not support that the ambulance transport on February 26, 2021, was medically reasonable and necessary for the enrollee based on the provided documentation.
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 transportation services have not been met. Specifically, the file does not support that other means of transport were contraindicated for the enrollee on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428-NH, A0428-HN) and ground mileage (A0425-NH, A0425-HN) provided on February 26, 2021.