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

We decided that the Plan does not have to pay for contact lens, other type (V2599) provided on February 6, 2020 by an out-of-network provider.
You asked the Plan to pay for the contact lens. You say that these are necessary for you. The Plan denied your request. The Plan says you exhausted your benefit allowance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the contact lens have not been met. You exhausted your benefit allowance because you already had contact lenses provided previously on June 13, 2018 and August 23, 2018 meeting your allowed amount.
Your EOC states, you have up to $125 combined allowance for eyeglasses or contact lenses in lieu of eyeglasses, every twenty-four (24) months. Therefore, we decided that the Plan does not have to pay for contact lens, other type (V2599) provided on February 6, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit for a new patient (99204) provided on February 7, 2020.You asked the Plan to pay for the new patient visit. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this claim has been billed with an incorrect procedure code for an established patient.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 99204 is office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99204 is not supported in the record. Specifically, the record indicates the member was seen as a new patient by a provider in the same group with the same specialty on July 23, 2019. This shows that the member is not a new patient as they have received professional services within the previous 3 years from this group.  Based on this information, we decided that Medicare rules for coverage of the new patient visit have not been met.Therefore, we decided that the Plan does not have to pay for an outpatient visit for a new patient (99204) provided on February 7, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient care you received from December 25, 2019, to December 29, 2019.You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the cost share.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 $395 copayment per day for days 1-4 for inpatient hospital care. Review of the file shows that you received 4 days of inpatient hospital care from December 25, 2019, to December 29, 2019. You have been asked to pay a $395 copayment per day for the services, totaling $1,580. The services fall within the inpatient hospital care 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 the inpatient care you received from December 25, 2019, to December 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 9, 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 screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The 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 rendered on January 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve longterm acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.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 the enrollee is currently receiving appropriate care at the current acute care facility. Discharge to a lower level of care could be considered based on the continued hospital course as improvement is noted thus far. The enrollee does not require any services at the LTACH that are not already available at the current acute care facility.Therefore, this request for LTACH transfer is not sufficiently supported and will be considered not medically necessary at this time.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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a measles, mumps and rubella (MMR) vaccine (90707) and administration (90471) provided on February 27, 2020.
You asked the Plan to pay for a MMR vaccine and administration. You say that this was necessary for you to travel. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of Medicare Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a MMR vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a MMR vaccine and administration. Therefore, we decided that the Plan does not have to pay for a measles, mumps and rubella (MMR) vaccine (90707) and administration (90471) provided on February 27, 2020.
Benefits for a MMR vaccine and administration 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 70450) provided on December 19, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in the payment for another service.The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 70450 is part of an edit pair with procedure code 70496. Procedure code 70496 is a column one code, and procedure code 70450 is a column two code. Procedure code 70496 has been paid for this date of service, which means that procedure code 70450 is not eligible for payment.Therefore, we decided that the Plan does not have to pay forthe services (CPT 70450) provided on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 lab services provided on February 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted ambulance service (A0999) ALS specialized service disposable supplies, IV drug therapy (A0394) demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device (94664) and noninvasive ear or pulse oximetry for oxygen saturation (94760) provided February 2, 2020.You asked the Plan to pay for the ambulance supplies. You say that you do not feel that you should have to pay this bill seeing how your health was very poor at the time of the call. This was truly an emergency.The Plan denied your request. The Plan says payment for these items is included in the payment for the ambulance transport. Medicare does not allow for separate billing of these services and supplies.The plan follows Medicare rules. The rules say that oxygen and other items and services provided as part of the transport are included in the fee schedule base payment rate and are not separately payable. Based on this information, we decided that Medicare rules for coverage of the ambulance supplies have not been met.Therefore, we decided that the Plan does not have to pay for unlisted ambulance service (A0999) ALS specialized service disposable supplies, IV drug therapy (A0394) demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device (94664) and noninvasive ear or pulse oximetry for oxygen saturation (94760) provided February 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for IRF care are not met. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 based on the documentation provided, you do not require the intensity of services provided at an IRF. Your condition does not require, nor does it appear you would be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (39328) provided on November 14, 2019 to December 11, 2019.
You asked the Plan to pay for home infusion therapy. You say that this was medically necessary. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
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 code 39328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (39328) provided on November 14, 2019 to December 11, 2019.
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. The Plan denied your request. The Plan says the enrollee's
medical condition is stable, and does not need close rehab physician care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 physician reviewer found
that you are becoming generally medically stable with urosepsis and encephalopathy. Once stable, there is no
evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per
week, or need for acute rehab nursing care. Currently you are at a maximum to dependent assist level. You
have confusion and unwillingness to participate in therapy, perhaps due to encephalopathy. While you may
benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive
therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary
approach to rehabilitation care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 you feel that LTACH care would be the best option in this case. The Plan denied your request. The Plan says the enrollee's needs can be met in the current facility.
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 the enrollee was admitted to the acute care hospital on 6/11/20 when she became hypotensive during dialysis. She was diagnosed with a complex urinary tract infection. It is noted that the enrollee has been requiring frequent paracentesis for ascites. On 6/27/20, the enrollee was lethargic. On 6/28/20, it is documented that the enrollee's prognosis is very poor. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The member is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 an external transmitter represented by CPT code A9277.
You asked the Plan to pre-approve an external transmitter. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested external transmitter is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. The records show that the transmitter you are requesting coverage for is used with a CGM that is considered non-therapeutic. Medicare only covers CGMs and supplies that are for use with a CGM that meets the definition of therapeutic. Therefore, we decided that the Plan does not have to pre-approve an external transmitter represented by CPT code A9277.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve reimbursement for travel and lodging for transplant services.
You asked the Plan to pre-approve reimbursement for travel and lodging for transplant services. You say that it is standard practice for patients undergoing this type of transplant to remain within a 30-minute drive from the facility for close monitoring for approximately 2-3 months post hospital discharge. The Plan denied your request. The Plan says the travel and lodging reimbursement is applicable when transplant care at an institute of Excellence facility is not available within 100 miles of the enrollee's home. Because these services are available within 100 miles of the enrollee's home, reimbursement is not approved.
The Plan must follow Medicare rules. Medicare rules say that in-network transplant services may be provided outside of the plan service area if the services are accessible and available to enrollees, and that service delivery is consistent with community patterns of care for original Medicare beneficiaries who reside in the same area. Medicare Advantage Plans do not have to cover travel and lodging expenses if the enrollee is going to a facility that is within a reasonable distance based on community patterns of care. We looked at the file and Medicare rules. The file shows that the distance from the facility to the enrollee's home is less than 100 miles. Therefore, we decided that the Plan does not have to pre-approve reimbursement for travel and lodging for transplant services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical information documenting medical necessity.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that there has not been at least three months of moderate to severe pain that hasn't responded to conservative care. Facet injections are generally not indicated in the face of radiculopathy as radicular pain implies a non-facet origin. The pain is associated with radiculopathy and the facet joint is not the main source of pain. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 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 according to the records provided, current clinical status required ongoing food reintroduction, therapy, oxygen supplementation, hemodialysis, and monitoring which warrants an acute care facility stay for at least a short while longer. However, the enrollee does not require any services available at the LTACH that are not already available at the current acute care facility. There was no indication that the enrollee would require at least 25 additional days of acute care. Therefore, based on the provided documentation, the requested LTACH services will be considered not medically necessary at this time. 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla.
You asked the Plan to pre-approve Otezla. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Otezla is 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 Otezla.
Benefits for Otezla may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.