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

We decided that the Plan does not have to pay for complete breast ultrasound (76641) screening digital breast tomosynthesis (77063) screening mammography (77067) provided August 17, 2021.
You asked the Plan to pay for the diagnostic service. You say that you believe your Plan provided reimbursement for an annual mammogram. The Plan denied your request. The Plan says Medicare does not pay for any covered items or service you get from an opt-out doctor or other provider.
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 complete breast ultrasound (76641) screening digital breast tomosynthesis (77063) screening mammography (77067) provided August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services (97012, G0283, 98943) provided August 16, 2021.
You asked the Plan to pre-approve the chiropractic services. You say that the services were medically necessary. The Plan denied your request. The Plan says these services are non-covered when performed by a chiropractor.
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 pre-approve chiropractic services (97012, G0283, 98943) provided August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hemodialysis provided on August 6, 2021.
You asked the Plan to pay for hemodialysis. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not billed with the appropriate G modifier.
The Plan must follow Medicare rules. Medicare rules say that hemodialysis code 90999 must be billed with the appropriate G modifier in field location 44, and if the modifier is not present the claim will be returned to the provider.
We looked at the file and Medicare rules. This claim does not include the appropriate G modifier for the billed code of 90999. Therefore, this claim is returned to you for correction. Based on this information, we decided that Medicare rules for coverage of hemodialysis have not been met. Therefore, we decided that the Plan does not have to pay for hemodialysis provided on August 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the endoskeletal system, below knee, alignable system addition (L5910).
You asked the Plan to pre-approve the endoskeletal system, below knee, alignable system addition. You say that you would like reconsideration because the requested addition is medically necessary. The Plan denied your request. The Plan says the notes do not show why your current alignable system cannot be used with the new socket.
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 endoskeletal system, below knee, alignable system addition. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed your medical need as the physician documentation does not support the vendor's claim that the you require the requested L9510 system.
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 endoskeletal system, below knee, alignable system addition have not been met. Therefore, we decided that the Plan does not have to pre-approve the endoskeletal system, below knee, alignable system addition (L5910).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee has concerns about Reclast due to heart issues associated with it. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Reclast before it will approve Prolia.
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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of Reclast. The documentation does not show that this drug would likely be less effective and/or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit (99215) provided on October 18,
2021, by an OON provider.
You asked the Plan to pay for a specialist office visit. You say that these services were medically necessary for
patient to have done as medical records support. You also say that this provider treats patients with excellent
care and should be reimbursed for services rendered. The Plan denied your request. The Plan says this provider
is not a network provider with the Plan, and the member was referred by a non-participating provider. 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 specialist office visit (99215) provided on
October 18, 2021, by an OON provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the emergency ambulance services (A0425 and A0429) provided on August 24, 2021.
You asked the Plan to pay for the emergency ambulance services. You say that you would like reconsideration because this claim was billed correctly and the services were medically necessary. The Plan denied your request. The Plan says that the diagnosis code does not match the services billed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has based their denial on the diagnosis codes billed on the claim. The Plan has not forwarded a claim to verify what diagnosis codes were billed. We are unable to verify the coding of these services without a claim. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the emergency ambulance services (A0425 and A0429) provided on August 24, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the payment for chiropractic services received from March 11, 2021 to August 3, 2021.
You asked the Plan to adjust the payment for the services. You say that you would like additional payment for these services. The Plan denied your request. The Plan says the claims were processed 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 out-of-network chiropractic services. You have been asked to pay 20% coinsurance for the services. the services falls within the out-of-network chiropractic services 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 adjust the payment for chiropractic services received from March 11, 2021 to August 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro 2 Motion G orthotic 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 medical studies haven't proven that the device is helpful for treatment of your health problem.
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 that based on the medical records provided, there is no documentation that the MyoPro 2 Motion G orthotic device at issue in this case meets Medicare criteria for medically reasonable and necessary. No records from the enrollee's treating provider were submitted explaining why the MyoPro 2 Motion G orthotic device at issue in this case is the most appropriate treatment for this enrollee's condition. In addition, current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment.
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 MyoPro 2 Motion G orthotic device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212), the X-ray of the chest (73110), and X-ray of knee (73562) provided on September 21, 2021.
You asked the Plan to pay for the medical services rendered by a chiropractor. You say that these chiropractor services should be considered like they were rendered by any other provider. The Plan denied your request. The Plan says services other than manual manipulation of the spine are not covered when rendered by a chiropractor.
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 pay for the office visit (99212), the X-ray of the chest (73110), and X-ray of knee (73562) provided on September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the 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 file shows that presumptive and definitive drug testing was provided. The 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 services 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 the drug testing services provided on June 23, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tablets.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Eliquis tablets.
Benefits for self-administered drug 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Grafix PL prime (Q4133).
You asked the Plan to pre-approve Grafix PL prime. You say that your foot is in danger. The Plan denied your request. The Plan says that this service is not medically necessary because you have not failed conservative therapy.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 Grafix PL prime. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this graft application appears within normal limits, medically reasonable and necessary. Standard wound care has been tried and failed. Skin substitute dressings have been proven safe and effective and are certainly within the standard of care for this type of wound. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Grafix PL prime have been met. Therefore, we decided that the Plan has to pre-approve Grafix PL prime (Q4133).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chronic care services provided on August 31, 2021, by an
OON provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were
not urgent, emergent, or 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 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 services 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 the chronic care services provided on August 31, 2021, by an 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 you would like reconsideration because the requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the IRF care.
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 you do not require the intensity of services provided at an IRF. Specifically, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from May 1, 2021 to May 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 the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that a RAP and a claim must be submitted for all episodes for which Medicare makes payment based on HIPPS codes. We looked at the file and Medicare rules. The file shows that the Plan did not receive the RAP within five calendar days of the start of care. 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 home health services rendered from May 1, 2021 to May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for treatment with an Optune Lua anticancer electrical stimulator (E0766) provided on March 30 to May 30, 2021.
You asked the Plan to pay for an Optune Lua device. You say that the item/service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for the item at issue have not been met.
The Plan must follow Medicare rules. Medicare rules say that the use of TTFT for any indications other than newly diagnosed GBM will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Optune Lua device have not been met. Specifically, the case record does not support that the item at issue was used for newly diagnosed GBM. Therefore, we decided that the Plan does not have to pay for treatment with an Optune Lua anticancer electrical stimulator (E0766) provided on March 30 to May 30, 2021
Appeal type: SNF
Decision: Unfavorable

November 6, 2020, through November 24, 2020 and billed with Patient Driven Payment Model (PDPM) score JDKE1.
You asked the Plan to pay for the SNF services billed with PDPM score JDKE1. You say that you would like reconsideration because the documentation submitted supports the PDPM score billed. The Plan denied your request. The Plan says the documentation submitted does not support PDPM score JDKE1.
The Plan must follow Medicare rules. Medicare rules say that that all SNF Part A inpatient services are paid under a prospective payment system (PPS). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services billed with PDPM score JDKE1 have not been met. Specifically, the Minimal Data Set (MDS) appears incomplete. Section GG of the MDS has not been coded. Without this information we are unable to validate the PDPM score billed. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on November 6, 2020, through November 24, 2020 and billed with Patient Driven Payment Model (PDPM) score JDKE1.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided November 11, 2021.
You asked the Plan to pay for the panoramic x-rays. You say that your dental issues are not resolved, and you cannot afford the cost. The Plan denied your request. The Plan says this type of x-ray is not covered under your 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 pay for the panoramic radiographic image (D0330) provided November 11, 2021.