Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve the concentrator. You say that the current tanks are too heavy to carry around. The Plan denied your request. The Plan says duplicate/redundant durable medical equipment is not covered.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 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 concentrator. Our reviewer says that the requested concentrator is not medically reasonable or necessary. Our physician reviewer found the record indicates that you are approved for home oxygen. You are ambulatory. The record does not indicate that you would benefit from the use of the portable oxygen system in the home. The elements of the coverage criteria are not satisfied. 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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Zoll life vest for the enrollee.
You asked the Plan to pre-approve the vest. You say that this is needed for a diagnosis of left ventricular systolic dysfunction. The Plan denied your request. The Plan says the criteria is not substantiated in the documentation supplied.
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 vest. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the record indicates that the enrollee has left ventricular systolic dysfunction. The record indicates that
the enrollee has an ejection fraction of under 30% and normal ventricular size. The record does not indicate
that the enrollee has had prior myocardial infarction. The record does not indicate a familial history or
inherited conditions with a high risk of life-threatening ventricular tachyarrhythmia nor does the record indicate
a history of ventricular fibrillation or a sustained, lasting 30 seconds or longer, ventricular tachyarrhythmia.
The elements of the coverage rule are not satisfied.
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 vest have not been met. Therefore, we decided that the Plan does not have to
pre-approve the Zoll life vest for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular RFA for the knee (CPT code 64624), for the enrollee.
You asked the Plan to pre-approve the service. You say that the procedure needs to be done. The Plan denied your request. The Plan says the service is considered experimental and investigational.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Genicular nerve RFA treatment is experimental for the treatment of knee pain. More research is needed to show safety and efficacy. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular RFA for the knee (CPT code 64624), for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest (71260) and a CT scan of the abdomen and pelvis (74177).
You asked the Plan to pre-approve a CT scan of the chest and a CT scan of the abdomen and pelvis. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT 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 pre-approve a CT scan of the chest and a CT scan of the abdomen and pelvis. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee is being treated for invasive, metastatic bladder cancer and has known rib metastases. The risk for further metastatic disease is real and it is reasonable based on NCCN guidelines to monitor this enrollee with imaging, especially CT. 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 CT scan of the chest and a CT scan of the abdomen and pelvis have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest (71260) and a CT scan of the abdomen and pelvis (74177).
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive procedure, by report (D1999) received February 24, 2021.
You asked the Plan to pay for the unspecified preventive procedure. You say that the Plan should cover the requested services. The Plan denied your request. The Plan says there is no coverage for the unspecified preventive procedure under your supplemental 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 unspecified preventive procedure, by report (D1999) received February 24, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on February 11, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment testing/panels.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on February 11, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services represented by code A0429 provided on January 14, 2021.
You asked the Plan to pay for the ambulance services. 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. The rules say in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is pronounced dead by an individual authorized by the State to make such pronouncements.
We looked at the file and Medicare rules. In this case, the file shows that the enrollee's time of death pronouncement was after dispatch and before the enrollee was loaded onboard the ambulance. Medicare payment is based on the provider's/supplier's BLS base rate, no mileage or rural adjustment is reported, and the provider/supplier must use the QL modifier when submitting the claim. In this situation, the correct CPT code to bill is A0428 for non-emergency services after assessment. Therefore, we decided that the Plan does not have to pay for the ambulance services represented by code A0429 provided on January 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that intensive physical therapy (PT), occupational
therapy (OT) and skilled therapy (ST) services are needed to maximize function and independence with
mobility and activities of daily living (ADL's). You state are at a high risk for falls, high risk for injury, and
high risk for re-admission to acute care and the above required services cannot be safely met with home health
services or a SNF at this time. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are living at home
after recent non-surgical treatment for a humerus fracture after a fall.
You have weakness. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no
documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different level of care. There is not a reasonable expectation that you will be able to fully participate in and
benefit from the intensive rehabilitation therapy program provided in an IRF.
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 IRF admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous (IV) pole and supplies rendered on November 27, 2020 to November 30, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 intravenous (IV) pole and supplies rendered on November 27, 2020 to November 30, 2020.
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 the additional routine transportation. You say that it is not affordable for you to take a taxi to this facility as it is about an hour away from your home. You feel that the Plan should continue to provide this transportation. The Plan denied your request. The Plan says you have exhausted your routine transportation benefit. No further trips can be approved.
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 20 trips per year.
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 trips
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on September 16, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.
We looked at the file and Medicare rules. Billed POS code 15 is for a mobile unit and the file shows that this is
the inappropriate POS for the services at issue. 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
testing services rendered on September 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - one surface, posterior (D2391) and the resin-based composite - two surfaces, posterior (D2392) received February 9, 2021.
You asked the Plan to pay for the two resin-based, posterior composites. You say that the Plan should cover the requested services. The Plan denied your request. The Plan says the requested services are not covered under your 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 resin-based composite - one surface, posterior (D2391) and the resin-based composite - two surfaces, posterior (D2392) received February 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601 ad 99602

You asked the Plan to pay for the home infusion/specialty drug administration services. You say that you feel these services should be covered. The Plan denied your request. The Plan says the services billed are not 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. 

We find that CPT codes 99601 and 99602 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion/specialty drug administration services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601 ad 99602
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on March
30, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for subsequent nursing facility care. You say that this doctor is the medical director
and sees patients on a random basis. Visits are not scheduled ahead of time therefore no authorization was
obtained. This doctor is the only doctor that is able to see patients. The Plan denied your request. The Plan says
enrollee's must receive their medical services from an in-network provider with the exception being urgent or
emergent services. Non-emergent services with non-contracted providers require prior authorization before
services being rendered.

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 subsequent nursing facility care (99308) provided
on March 30, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation and panoramic x-ray provided on December
3, 2020 and the extraction and sedation provided on January 20, 2021.

You asked the Plan to pay for the consultation, panoramic x-ray, extraction and sedation. You say that your regular dentist couldn't pull your tooth, so you were told to go to a surgeon dentist. You say that you are paying for dental coverage and the Plan should pay more. The Plan denied your request. The Plan says a consultation and sedation are not covered benefits and the benefit for the x-ray has been exceeded. The Plan also says that the extraction was covered at 50%.

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 Plan also has a maximum benefit of four bitewing x-rays or one full mouth x-ray per calendar year. The Plan paid for four bitewing x-rays provided on March 12, 2020, which exhausted your benefit. The Plan also paid 50% of the cost for the extraction per the Plan contract and the consultation and sedation are not covered benefits. Therefore, we decided that the Plan does not have to pay for the consultation and panoramic x-ray provided on December 3, 2020 and the extraction and sedation provided on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) provided on March 8, 2021.
You asked the Plan to pay for an intraoral complete series of radiographic images. You say that you want help paying this charge. The Plan denied your request. The Plan says the service at issue is not a covered 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 an intraoral complete series of radiographic images (D0210) provided on March 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of abscess coded 10061 provided
on June 21, 2020.

You asked the Plan to pay for the incision and drainage of abscess. 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 supported by the
documentation.

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 10061 is incision and drainage of abscess (eg, carbuncle,
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or
multiple.

We find that CPT code 10061 is not supported in the medical record. Specifically, the documentation submitted
indicates an incision and drainage of abscess; simple or single was performed; therefore, the billed service
cannot be verified. Based on this information, we decided that Medicare rules for coverage of the incision and
drainage of abscess have not been met. Therefore, we decided that the Plan does not have to pay for the
incision and drainage of abscess coded 10061 provided on June 21, 2020.