Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested transportation.
You asked the Plan to pre-approve the transportation. The Plan denied your request. The Plan says the distance the member would need to travel is greater than the allowed distance of 60 miles per trip.
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 routine transportation when 60 one-way trips each calendar year to and from locations within the local service area (60-mile limit per one-way trip) when obtaining Plan covered services. We looked at your request, the records in the case file, and the rules. The file shows that the requested transportation is to a provider's office with a distance greater than 60 miles. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve the requested transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT angiography of the chest (non-coronary) for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there are no results from Peak Flow at one second.
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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found a chest CT angiogram is considered not medically necessary. The enrollee has shortness of breath and wheezing, which improves with bronchodilators. Echocardiography shows HFrEF with no pulmonary hypertension or RV enlargement. The suspicion for pulmonary embolism seems low, and a concern for this diagnosis is not raised in the clinical documentation. 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 pre-approve CT angiography of the chest (non-coronary) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral to a oromaxillary facial surgeon.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network oromaxillary facial surgeons available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral to a oromaxillary facial surgeon.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on November 29, 2020.
You asked the Plan to pay for the paramedic intercept services. You say that this service did not assist in any way. The Plan denied your request. The Plan says this item is not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on November 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says LTACH care is not medically necessary as alternative care can be reconsidered for alternate level of care when enrollee is stable for transfer.
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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee 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. 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-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).
You asked the Plan to pre-approve a home ventilator. You say that this request is medically necessary. The
Plan denied your request. The Plan says rules for a home ventilator have not been met.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 home ventilator. Our reviewer says
that the request is not medically reasonable and necessary. Our physician reviewer found based on the medical
records provided there is documentation that you have chronic respiratory failure consequent to chronic
obstructive pulmonary disease. However, there is no documentation that the ventilator at issue is medically
necessary and reasonable for you as the records do not clearly show that a Bilevel Positive Airway Pressure
(BiPAP) device (E0471) with average volume-assured pressure support (AVAPS) adaptive servo ventilation
technology would not meet your needs.
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 home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection provided on December 11, 2020.
You asked the Plan to waive the copayment for an epidural injection. You say that you disagree with the charges because you were not aware of the high charges and it was not a surgical procedure. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The enrollee has been asked to pay a $250 copayment for an epidural injection. An epidural injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an epidural injection provided on December 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's condition necessitates LTACH care. The Plan denied your request. The Plan says LTACH care is not medically necessary as care can be provided in current inpatient 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee 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-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Atenolol tablets.
You asked the Plan to pre-approve Atenolol tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Atenolol tablets are not covered under the enrollee's Medicare Part B benefit.
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 Atenolol tablets.
Benefits for Atenolol tablets 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's condition does not meet the criteria for this monitor.
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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is not using insulin, which is a requirement for covering this monitor. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0823).
You asked the Plan to pre-approve a power wheelchair. You say that this would make your home life easier. The Plan denied your request. The Plan says the records do not show that you meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that for a power mobility device to be covered, the beneficiary must have a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living that cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker, and the beneficiary must not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair.
We looked at the file and Medicare rules. The submitted medical records show that you currently ambulate using a cane. The records do not show that your mobility limitation is not resolved with a cane or that you cannot propel a manual wheelchair. Based on this information, we decided that Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0823).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.
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 reviewer says
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH)
following a stroke. The enrollee is not intubated/ventilated. The provider believes the enrollee is appropriate for
Hospice, but her family has declined that level of service. There is no evidence that the enrollee requires
services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care,
there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH
until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level
of care for any ongoing long term care needs.
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-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device remains experimental. More research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of an advanced pneumatic compression device (PCD E0652).
You asked the Plan to pre-approve advanced PCD. You say that this device is not available from an in-network provider and the enrollee had a successful trial with it. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the record shows the enrollee does not have lymphedema extending into the trunk or abdomen.
The Plan follows Medicare rules. Medicare rules say that an advanced pneumatic compression device E0652 may be covered for enrollee's with lymphedema of an extremity extending onto the chest, trunk, and/or abdomen past the limits of a standard compression sleeve which has failed to improve with a 4-week trial meeting certain guidelines. 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 advanced PCD. Our reviewer says that the enrollee does not meet the Medicare criteria for use of the requested E0652 PCD. Our physician reviewer found the documentation does not support that the enrollee has failed at least 4 weeks of conservative care with gradient compression bandaging, extremity elevation, and an exercise program. Furthermore, there is no documentation to support that the enrollee has lymphedema of an extremity that extends onto the chest, trunk, and/or abdomen that extends past the limits of a standard compression sleeve. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of advanced PCD have not been met. Therefore, we decided that the Plan does not have to pre-approve use of an advanced pneumatic compression device (PCD E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve second opinion consult (92004) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve second opinion consult. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the Plan has multiple in-network providers available to provide the requested services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve second opinion consult (92004) to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on October 20, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you are unable to receive standard colonoscopy screenings and the CT scan is a necessary replacement. 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 $110 copayment for CT scans. You have been asked to pay the allowed amount of $108.05, which is less than the $110 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 October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies (CPT 99072) provided to the enrollee on November 4, 2020.

You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. The Plan says this is a bundled-only procedure, and not separately reimbursable.

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 99072 is "Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease." 

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 supplies. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found on October 27, 2020 CMS assigned CPT 99072 procedure status "B". Per CMS status "B" means the services are considered "bundled". Therefore, this service is bundled into the primary service performed. 

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 supplies have not been met. Therefore, we decided that the Plan does not have to pay for supplies (CPT 99072) provided to the enrollee on November 4, 2020.