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

We decided that the Plan does not have to pay for the Revascularization (37222) services provided on June 5,
2019.
You asked the Plan to pay for the Revascularization (37222) services. You say that the medical records support
the billing of CPT code 37222. The Plan denied your request. The Plan says the medical records do not support
the billing of CPT code 37222.
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 37222 is Revascularization, endovascular, open or
percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately
in addition to code for primary procedure).
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 Revascularization (37222) services. Our
reviewer says that the medical records do not support the billing of CPT code 37222. Our physician reviewer
found the operative note shows that the common iliac artery and external iliac artery lesions were treated as a
contiguous segment angioplastied with the same balloon. The use of the add-on code 37222 in addition to the
base code for iliac artery angioplasty is not supported in the medical records provided.
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 Revascularization (37222) services have not been met. Therefore, we
decided that the Plan does not have to pay for the Revascularization (37222) services provided on June 5, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pre-approveroutine transportation.You asked the Plan to pre-approveroutine transportation. You say that you need to go to this facility and no other option is close to your home.The Plan denied your request. The Plan says that the denial of authorization for this routine transportation is correct, because routine transportation beyond 50 miles per one-way trip is not covered by the Plan.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 48 one-way trips per calendar year. Each one-way trip must not exceed 50 miles. We looked at your request, the records in the case file, and the rules. A one-way trip from your home to the requested destination does not exceed 50 miles, nor does a return trip from the destination to your home. Based on this information, we decided that the Plan's rules for coverage of routine transportation have been met.Therefore, we decided that the Plan has to pre-approveroutine transportation.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 toopen 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 provided by you April 15, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered
benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on April 15, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you April 15,
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lidocaine infusion.
You asked the Plan to pre-approve lidocaine infusion. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 lidocaine infusion. Our reviewer says that the requested lidocaine infusion is not medically reasonable and necessary in this case. Our physician reviewer found that this is an experimental/investigational use of lidocaine. This is off-label and its use here is based on anecdotal evidence only. There are FDA approved medications for fibromyalgia which the enrollee has not trialed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lidocaine infusion have not been met. Therefore, we decided that the Plan does not have to pre-approve lidocaine infusion.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on June 30, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 30, 2020. The ambulance benefit is a transportation benefit.When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided  on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210), the removal of an impacted
tooth (D7220 x 2), and the unspecified preventive dental service (D1999) provided on July 8, 2020.
You asked the Plan to pay for the dental services. You say that the first time you called and spoke to someone
about setting up a dental plan, you were told you could write a letter and appeal this. You say that you would
have signed up with platinum insurance if you would have been given the option to. You also say that if you
would have been given the correct information you would have chosen the correct dental plan to suit you from
the start. The Plan denied your request. The Plan says surgical extraction is not listed as a covered service. The
Plan says removal of an impacted tooth is not listed as a covered service. The Plan says unspecified preventive
dental service is not listed as a covered service either. The Plan also says any services not listed are not
covered.
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
surgical extraction (D7210), the removal of an impacted tooth (D7220 x 2), and the unspecified preventive
dental service (D1999) provided on July 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says there is no clinical advantage of an LTACH over continued care at the acute hospital.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee presented to the emergency room with a complaint of abdominal fullness and jaundice. Hispost-operative course has been complicated by respiratory failure which has resolved, acute renal failure necessitating three time a week hemodialysis, and failure to thrive. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care facility.Theenrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 3, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed 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. We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. The material for examination is whole blood, serum, plasma, or cerebrospinal fluid. The records provided shows that a urine sample was provided. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOsphena.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.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 thatthe Plan does not have to pre-approveOsphena.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from July 26, 2020 to July 30, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the inpatient services were medically necessary.The Plandenied your request. The Plan says that the enrollee's care did not meet medical necessity for acute inpatient hospital level of care.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that theenrollee'snecessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from July 26, 2020 to July 30, 2020.
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 toopen the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on August 20, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges because the Plan would not approve a PET scan and now the mass has grown. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for a CT scan. You have been asked to pay a $150 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 a CT scan provided on August 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveSNF admission. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you received oral and inhaled medications. You had stable vital signs. You required stand-by assistance to moderate assistance with functional mobility. You remained non-ambulatory, which is your baseline. You required varying assistance with activities of daily living. The documentation does not support that you require the specialized skills, knowledge, or judgment of a skilled professional nurse orqualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis, at a SNF 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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for critical care provided on June 16, 2020.
You asked the Plan to waive the deductible for critical care. You say that you requested to not have any out-of-network providers assist during the surgery. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible for inpatient hospital care. You received critical care on June 16, 2020. The record shows that you had paid $0 toward the $500 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $238.89. The item or service you asked the Plan to waive the deductible for falls within the benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time critical care was received on June 16, 2020. Therefore, we decided that the Plan does not have to waive the deductible for critical care provided on June 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99282 and related
services coded 80048, 81001, 85025, 96365, and J0696 provided on June 5, 2020.
You asked the Plan to pay for the emergency department visit and related services. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the claims were billed
incorrectly.
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 99282, 80048, 81001, 85025, 96365, and J0696 are not supported in the medical
record. Specifically, Billed HCPCS code 93005 is a type STV packaged procedure and was billed with HCPCS
code 99285 that denied with reason medical visit on the same day as a type T or S procedure without modifier
25. This denial is generated if any E&M code that occurs on a day with a type "T" or "S" procedure does not
have a modifier of 25. All the remaining lines were denied to correct the OCE 21 denial. Based on this
information, we decided that Medicare rules for coverage of the emergency department visit and related
services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency
department visit coded 99282 and related services coded 80048, 81001, 85025, 96365, and J0696 provided on
June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, vertical bitewing x-rays and panoramic x-ray provided on June 16, 2020.
You asked the Plan to pay for the comprehensive oral evaluation, vertical bitewing x-rays and panoramic x-ray. You say that you were told that these charges were covered in full by insurance. The Plan denied your request. The Plan says payment cannot be issued for services performed by a provider that has opted out of Medicare.
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 the comprehensive oral evaluation, vertical bitewing x-rays and panoramic x-ray provided on June 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea group 2 power wheelchair.You asked the Plan to pre-approvea group 2 power wheelchair. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested device is not medically necessary.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 group 2 power wheelchair. Our reviewer says that the documentation does not support that the requested power wheelchair is medically reasonable or necessary. Our physician reviewer found the documentation does reveal that youhave a personal mobility deficit that impairs participation in mobility related activities of daily living in the home. The documentation does reveal that your mobility deficit is unable to be effectively helped by a walker or cane due to weakness of the extremities. The documentation is not clear that your mobility deficit is unable to be helped by a manual wheelchair as the power operated vehicle assessment states that you live with your daughter who is able to assist you. In addition, the documentation is unclear if you are given a wheelchair or other mobility device if you are unable to operate it. The documentation is not clear that you can safely maneuver the power operated vehicle in the home or that the requested power operated vehicle will significantly improve activity of daily living performance in the home as there is no detailed evaluation of the home with measurements. Therefore, you do not meet criteria for the requested power wheelchair.
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 group 2 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approvea group 2 power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head/brain.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the submitted records show that you
have migraines and dizziness. You have had repeated imaging studies. There is no documentation to support
that a CT scan of the head/brain is reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a computed tomography (CT) scan of the head/brain.