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

We decided that the Plan does not have to pre-approve implantation of a leadless pacemaker for the enrollee.
You asked the Plan to pre-approve a leadless pacemaker. You say that these services are medically necessary.
The Plan denied your request. The Plan says that Leadless pacemakers are only covered as part of a covered
clinical study.
The Plan must follow Medicare rules. Medicare rules say that leadless pacemaker devices are only covered in a
Medicare-approved clinical study. Leadless pacemakers are non-covered outside of an approved study.
We looked at the file and Medicare rules. The requested leadless pacemaker procedure is not covered by
Medicare outside of an approved clinical study. The file does not indicate the enrollee is enrolled in an
approved study. Based on this information, we decided that Medicare rules for coverage of a leadless
pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation
of a leadless pacemaker for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office consultation represented by code 99244 provided on March 3, 2020.
You asked the Plan to pay for code 99244. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, CPT code 99244 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes.
Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for the office consultation represented by code 99244 provided on March 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient professional services and the outpatient surgery services provided on December 9, 2020.
You asked the Plan to waive the copayments for the outpatient professional services and the outpatient surgery services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an outpatient professional services and outpatient surgery on the date of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
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 $45
copayment for provider and professional services provided by a specialist and a $275 copayment for outpatient surgery. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received professional services on December 9, 2020. You have been asked to pay a $40.96 copayment for the professional services, which is less than the contracted $45 copayment amount. The professional services fall within the Outpatient diagnostic tests benefit category. The file shows that you also received outpatient surgery services on December 9, 2020. You have been asked to pay a $138.74 copayment for the outpatient surgery services, which is less than the $275 copayment amount. The outpatient surgery services fall within the Outpatient surgery benefit category. This means that you have been asked to pay the correct amounts 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 outpatient professional services and the outpatient surgery services provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic injection services (96372, J3490) provided March 2, 2021.
You asked the Plan to pay for the therapeutic injection services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says these services are not covered.
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 the therapeutic injection services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this patient is a 56 year old male with feet pain, paresthesia, chronic pain syndrome, and gait abnormality. Multivitamin injections (compounded Nutria) were requested along with lidocaine to the affected areas. However, there is insufficient support made that injecting vitamins and nutrients to the injured area will be more effective than eating these nutrients from natural foods. Without sufficient support made for this request, the multivitamin injection (Nutria) will be considered 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 the therapeutic injection services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic injection services (96372, J3490) provided March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on March 16, 2021.
You asked the Plan to pay for a periodic oral evaluation, a teeth cleaning, and bitewing radiographic images. You say that you were told the services would be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided December 5, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services to be provided by an out-of-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 physician services provided December 5, 2020 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled medications, had stable vital signs, and was treated for pain with effect. The enrollee received physical therapy, occupational therapy, and speech therapy in the acute hospital. The enrollee required varying assist with activities of daily living. The enrollee could negotiate 12 stairs with supervision/set-up assist. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on September 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services cannot be verified.
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 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes". We find that CPT code 99291 is not supported in the medical record. Specifically, the records provided do not show that 30-74 minutes of critical care services were provided on the date of service in question. Based on this
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided on September 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation
(A0428, A0425) provided on April 19, 2021.
You asked the Plan to waive the copayment for non-emergency ambulance transportation. You say that you
were told there would be no charge for the services. The Plan denied your request. The Plan says the
copayment was 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 $200
copayment for ambulance services.
You have been asked to pay a $200 copayment for non-emergency ambulance transportation. The services at
issue fall within the ambulance 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 waive the copayment
for non-emergency ambulance transportation (A0428, A0425) provided on April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-intravenous conscious sedation (D9248) provided on
March 18, 2021.
You asked the Plan to pay for the sedation services. You say that you did not know this service would not be
covered. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the nonintravenous
conscious sedation (D9248) provided on March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 9, 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. 

Review of the file shows that the ordering provider denied writing the order for generic testing for the enrollee. This means that the laboratory 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 April 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.
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 48 one-way transportation trips when each one-way trip does not exceed 50 miles.
We looked at your request, the records in the case file, and the rules. 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 mileage
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device.
You asked the Plan to pre-approve the MyoPro Motion G Orthotic device. You say that this item is medically
necessary for the enrollee's condition. The Plan denied your request. The Plan says the item requested has
deluxe features that exceed the enrollee's needs.
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 MyoPro Motion G Orthotic device.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found 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 this patient, 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 the MyoPro Motion G Orthotic device have not been met. Therefore, we
decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a PET/CT scan provided to the enrollee on January 10, 2021.
You asked the Plan to pay for the scan. You say that this is medically necessary. The Plan denied your request. The Plan says claims must be billed with an appropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the scan. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there was no appropriate diagnosis code listed in the report of the scan from January 10, 2021. This is needed in order to qualify for reimbursement. The dictated history "chronic disease of the tonsils and adenoids" is not a recognized indication for this scan. 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 scan have not been met. Therefore, we decided that the Plan does not have to pay for a PET/CT scan provided to the enrollee on January 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on December 6 - December 9, 2019.
You asked the Plan to pay for the inpatient hospital services. You say that the documentation provided supports the services in dispute. The Plan denied your request. The Plan says the documentation and clinical evidence available for review fail to support an exacerbation of congestive heart failure (CHF).
The Plan follows Medicare rules. Medicare rules say that hospitals must provide proper information about the patient in order for the correct DRG to be assigned. We asked our coding 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 inpatient hospital services. Our reviewer says that the criteria for coverage have not been met. Our coding reviewer found the documentation submitted was reviewed and does not support ICD 10 I50.23 (Acute on Chronic Systolic (congestive) heart failure). Discharge summary documents systolic congestive heart failure, however, no care for acute on chronic congestive heart failure was documented. Documentation does not document the care for acute on chronic CHF and therefore, ICD 10 150.23 should not be reported for this hospital stay. 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on December 6 - December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies (T4535) provided from November 6, 2020, to June 16, 2021.

You asked the Plan to pay for incontinence supplies. You say that your provider did not order supplies from the correct company and you cannot afford the bills. The Plan denied your request. The Plan says these items are only covered when purchased from participating stores.

The Plan must follow Medicare rules. Medicare rules say that incontinence supplies are not covered because they are hygienic items that are non-reusable. Though the Plan offers an over-the-counter benefit that covers incontinence supplies, it only covers supplies purchased from a participating store. 

We looked at the file and Medicare rules. The incontinence supplies at issue were not purchased from a Plan-participating store. Based on this information, we decided that Medicare rules for coverage of incontinence supplies have not been met. Therefore, we decided that the Plan does not have to pay for incontinence supplies (T4535) provided from November 6, 2020, to June 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ganglion impar block bilateral.
You asked the Plan to pre-approve a ganglion impar block bilateral. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 a ganglion impar block bilateral. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the Ganglion Impar block is one central injection and not a bilateral right and left injection. The request to complete the Ganglion Impar block as a bilateral procedure with coverage of 64520 x 2 is inappropriate. The items/services at issue in this case is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a ganglion impar block bilateral have not been met. Therefore, we decided that the Plan does not have to pre-approve a ganglion impar block bilateral.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning rendered on February 3, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 99497 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 99497 is Advance care planning by other qualified health
care professional, first 30 minutes.
We find that CPT code 99497 is not supported in the medical record. Specifically, there is no documentation of
the first 30 minutes of advance care planning spent on the enrollee. 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 advance care planning rendered on February 3, 2021.