Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional hours of neuropsychological testing (96133, 96139).  You asked the Plan to pre-approve additional neuropsychological testing. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.  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 additional neuropsychological testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has shown an impairment in functioning as documented. The enrollee has been showing difficulty with memory issues as outlined. There was no documentation that justifies the extra amount of time in testing and assessment. Based on the records provided, the enrollee does not meet the criteria for additional neuropsychological testing.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pre-approve additional hours of neuropsychological testing (96133, 96139).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a seat lift mechanism chair.  You asked the Plan to pre-approve a seat lift mechanism chair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically necessary.  The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a seat lift mechanism chair. Our reviewer says that the documentation does not support that the requested item is medically reasonable or necessary. Our physician reviewer found the documentation does not support that you have severe arthritis of the hip or knee. You do not have a severe neuromuscular disease. You are not completely incapable of standing up from a regular armchair or any chair in her home. You have the ability to ambulate. The documentation does not reveal objective imaging evidence of documentation of (a) severe arthritis of the hip or knee; and/or (b) a neuromuscular disease. The medical progress notes do include a seat lift in the course of treatment. The seat lift is not likely to (a) effect improvement in your condition; or (b) arrest or retard deterioration in your condition. The records do not show that you are totally incapable of standing from a chair in the home. Therefore, you do not meet criteria for the requested item.  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 seat lift mechanism chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism chair.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve knee replacement surgery to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve knee replacement surgery. You say that you need this surgery. The Plan denied your request. The Plan says that you are able to see a provider within the network.  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 knee replacement surgery 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 a methylenetetrahydrofolate reductase gene analysis (81291) provided on August 11, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for a methylenetetrahydrofolate reductase gene analysis. You say that this provider is the sole source provider of the GeneSight test that represents most clinically relevant and comprehensive genotyping for pharmacokinetic and pharmacodynamics genes that are involved in psychotropic drug metabolism and response. The Plan denied your request. The Plan says the non-urgent services are not authorized because the provider is a non-network provider with the member's health plan, and the referring provider is another non-network provider.  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 a methylenetetrahydrofolate reductase gene analysis (81291) provided on August 11, 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 June 15, 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 billed 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.  The test at issue in this appeal 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 provided on June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the debridement (11046) provided on January 27, 2021.  You asked the Plan to pay for the debridement. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 11046 is debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure).  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 debridement. Our reviewer says that CPT code 11046 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does not include debridement measurement for this date of service, and therefore cannot be verified. The procedure was documented without measurements to confirm each additional 20 sq cm.  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 debridement have not been met. Therefore, we decided that the Plan does not have to pay for the debridement (11046) provided on January 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve psychological or neurobehavioral status exam, per hour (96116 x1) two or more psychological or neuropsychological tests and scores them requiring an additional 30 minutes beyond the initial 30 minutes (96139 x1).  You asked the Plan to pre-approve neuropsychology testing. You say that the exam for this enrollee will require some flexibility in order to provide them with adequate medical care. The Plan denied your request. The Plan says the test time is considered to be excessive and 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 neuropsychology testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review of the records provided, it was noted that this enrollee's provider is asking for an excessive amount of the procedure beyond which is approved by LCD 34632. This enrollee has shown an impairment in functioning as documented. He has been showing difficulty with memory issues as outlined using the interpretation. There was no documentation that justifies the extra amount of time in the testing and assessment. Based on review the records provided in the information provided this enrollee does not meet the criteria for additional neuropsychological testing beyond which is approved by LCD 34632 based on the enrollee's clinical history and documentation presented.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuropsychology testing  have not been met. Therefore, we decided that the Plan does not have to pre-approve psychological or neurobehavioral status exam, per hour (96116 x1) two or more psychological or neuropsychological tests and scores them requiring an additional 30 minutes beyond the initial 30 minutes (96139 x1).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a urinalysis, automated, with microscopy (81001) provided on August 3, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for a urinalysis, automated, with microscopy. You say that the provider is an independent laboratory and does not receive any patient information until after services are rendered. You also say that the patient was seen by an in-network physician with no control over the laboratory used and should not be penalized by having this claim processed as out of network. The Plan denied your request. The Plan says the member was referred by a non-participating provider and the referral was not authorized by the attending physician.  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 a urinalysis, automated, with microscopy (81001) provided on August 3, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for incontinence supplies on August 12, 2021.  You asked the Plan to pay for incontinence supplies. You say that the supplies are needed. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve receiver (monitor), dedicated, for use with therapeutic CGM system (CPT code K0554) and supply allowance for therapeutic CGM includes all supplies and accessories, 1 month supply = 1 unit of service (CPT code K0553).  You asked the Plan to pre-approve the CGM and supplies. You say that this should be covered because you have been using the Freestyle Libre 2 and are running low on the last sensor. The Plan denied your request. The Plan says a CGM for monitoring is not reasonable and medically necessary.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that you do not take insulin and do not adjust an insulin dose based on blood glucose results. You intend to use a CGM for monitoring, not therapeutic reasons. A therapeutic CGM is used to adjust insulin medication, usually on a real time basis, while monitoring (non-therapeutic) of blood glucose is done with a blood glucose meter (BGM) or a blood test measuring HgbA1C. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve receiver (monitor), dedicated, for use with therapeutic CGM system (CPT code K0554) and supply allowance for therapeutic CGM includes all supplies and accessories, 1 month supply = 1 unit of service (CPT code K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (CPT code D5223) and immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (CPT code D5224).  You asked the Plan to pre-approve the dental services. You say that you are unable to eat, and it is causing additional health concerns. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.  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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pre-approve immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (CPT code D5223) and immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (CPT code D5224).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional units of 95861 and 95868 for neuromonitoring services provided on June 30, 2020.  You asked the Plan to pay for the additional units as billed. You say that this was billed correctly. The Plan denied your request. The Plan says more than one unit cannot be paid of codes 95861 and 95868.  The Plan follows Medicare rules. Medicare rules say that MUEs with an MAI of 3 may be bypassed when medical review determines they were actually provided and were medically necessary.   Code 95861 is defined as Needle electromyography (EMG); 2 extremities with or without related paraspinal areas, and has an MUE of 1 unit. Code 95868 is defined as Needle electromyography; cranial nerve supplied muscles, bilateral, and has an MUE of 1 unit. Both have an MAI of 3.  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 additional units as billed. Our reviewer says that the documentation does not support reporting additional units of the codes at issue. Our physician reviewer found the member underwent cervical spine surgery and IONM services were provided during the course of the surgical procedure. EMG was one of the modalities monitored during the course of the procedure. However, the placement of the EMG needles in this case as described in the clinical documentation did not reflect the provision of a clinically distinct/unique services. Rather, the services provided would have otherwise been adequately coded for by the use of a single unit of the CPT code. In as much additional units of the codes are not supported by the records.  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 additional units as billed have not been met. Therefore, we decided that the Plan does not have to pay for the additional units of 95861 and 95868 for neuromonitoring services provided on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on July 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for a domiciliary or rest home visit. You say that the provider is in the credentialing process and the group is already participating. You also say that the enrollee sought out medical attention from your provider. The Plan denied your request. The Plan says this provider is not a network provider with this Plan. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  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 a domiciliary or rest home visit (99336) provided on July 9, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy (97110, 97140, 97162) provided from July 14, 2021, to July 28, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for physical therapy. You say that you have informed the Plan each year for the past 20 years that I will be out of state for the summer (from May 1, to October 1) each year. The Plan denied your request. The Plan says your benefit plan does not cover services by out of network providers except in emergencies and other rare situations when the Plan has pre-authorized out of network use.  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 physical therapy (97110, 97140, 97162) provided from July 14, 2021, to July 28, 2021 by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Synvisc (J7325).  You asked the Plan to pre-approve Synvisc. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthovisc and Monovisc.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Synvisc. Our reviewer says that the requested drug, Synvisc, is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drugs, Monovisc and Orthovisc. The reviewer found that there is no documentation provided indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the requested drug is not medically necessary as the step therapy criteria has 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 Synvisc have not been met. Specifically, the file shows that the enrollee has not tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a stair glide.  You asked the Plan to pre-approve a stair glide. You say that the enrollee has knee pain and underlying osteoarthritis. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.   While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.