Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the telephone evaluation and management service represented by code 99443 provided on April 12, 2021.
You asked the Plan to pay for code 99443. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan provided medical records for the incorrect date of service. The file does not show that the Plan made any attempts to obtain the correct medical records for the April 12, 2021 date of service in dispute. We find that the Plan has not substantiated their reasoning for the denial of payment. Therefore, we decided that the Plan has to pay for the telephone evaluation and management service represented by code 99443 provided on April 12, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection administration (J7323, 20610) provided June 30, 2020.
You asked the Plan to waive the copayment for the injection administration. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $30 copayment for specialist visits. You have been asked to pay a $30 copayment for the injection administration. The injection administration falls within the specialist visits 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 an injection administration (J7323, 20610) provided June 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to LTACH.
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 an outside hospital with shortness of breath due to acute on chronic ischemic cardiomyopathy. He was found to have a cavitary lung lesion as well as evidence of early
cirrhosis. He was then transferred to the current facility for a higher level of care. The enrollee is awaiting permanent vascular access for hemodialysis. The enrollee continues to receive necessary acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided from March 6, 2021 to March 10, 2021.
You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 99291.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress notes for March 6, 2021, March 8, 2021, March 9, 2021, and March 10, 2021 do not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services represented by code 99291 provided from March 6, 2021 to March 10, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a portable ventilator for the fifth month moving onward.
You asked the Plan to pre-approve a portable ventilator. You say that a portable ventilator is medically necessary. The Plan denied your request. The Plan says that that there is no evidence that the requested mechanical ventilator is indicated after recovery of this new acute illness.
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 portable ventilator. Our reviewer says that a portable ventilator is medically reasonable and necessary. You have recently been hospitalized from July 28, 2021, through August 12, 2021, with chest pain and cough productive of white sputum. You do have a history of oxygen dependent chronic obstructive pulmonary disease (COPD) and sleep apnea on continuous positive airway pressure (CPAP), moderate pulmonary hypertension, coronary artery disease status post coronary artery bypass graft (CABG), and a recent CoViD-19 infection. Bilevel positive airway pressure (BIPAP) has been tried but the pCO2 remains greater than 50. You have a neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. The documentation in the medical record does support that the ventilator at issue is medically necessary and reasonable for you past the first four months. Our physician reviewer found that your condition meets Medicare criteria for a portable ventilator. 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 portable ventilator have not been met. Therefore, we decided that the Plan has to pre-approve a portable ventilator for the fifth month moving onward.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) provided on November 6, 2020.
You asked the Plan to pay for the ground mileage and non-emergent ambulance transport. You say that on November 6, 2020 the hospital arranged for the transportation to take you home. You also say that you had no way to get home because you did not have your car, and no way to call for transportation. The Plan denied your request. The Plan says that ambulance transport is covered if you could not have used another means of transportation without endangering your health. The Plan also says that the transport you received does not meet this criteria.
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. For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. The Plan follows these rules. You were referred for the ground mileage and non-emergent ambulance transport by a contract provider. Non-emergency ambulance transportation is an example of a service that is normally not covered but could be covered under some conditions. The EOC is therefore, not adequate notice of non-coverage in this case. The file does not show that the Plan provided notice that the ground mileage and non-emergent ambulance transport would not be covered. Under Medicare rules, this means the ground mileage and non-emergent ambulance transport is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) provided on November 6, 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 to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. You say that you need this to breathe. The Plan denied your request. The Plan says you can be treated with a bi-level positive airway pressure (BiPAP) device.
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 requirements for coverage of a home ventilator have not been met. Our physician reviewer found the records show that you have severe interstitial lung disease and are pending evaluation for lung transplantation. There is no documentation to support a diagnosis of chronic obstructive pulmonary disease, and this diagnosis is not listed on either the outpatient visits or the admission notes during the hospitalization. There is no documentation of carbon dioxide retention while the patient is medically stable. Possible causes of carbon dioxide retention have not been addressed. Medicare does not cover a home ventilator when used as a bi-level positive airway pressure (BiPAP) device. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered because it is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a plastic surgery consult to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the out-of-network plastic surgery consult. You say that the out-of-network evaluation is medically necessary. The Plan denied your request. The Plan says there are in-network providers available that can provide this service.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a plastic surgery consult to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 27, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for physician services provided on July 27, 2020 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox Solution, 100 units (J0585).
You asked the Plan to pre-approve Botox. You say that the requested Botox injection would prevent spasms that cause the enrollee's eyelid to turn inward. The Plan denied your request. The Plan says the enrollee does not have any stated contraindications to the preferred products. The Plan says that the enrollee has not tried any of the preferred agents. The Plan also says that the provider does not provide a rationale for use of the non-preferred product for safety or efficacy.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Botox. Our reviewer says that the requested Botox solution is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drug, Xeomin. The reviewer found that there is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria has not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Specifically, the record shows that the enrollee has not tried and failed the Plan's preferred drug, Xeomin. Therefore, we decided that the Plan does not have to pre-approve Botox Solution, 100 units (J0585).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for 2 cataract procedures (66984) provided August 11, 2020 and August 25, 2020.
You asked the Plan to waive the copayment for the cataract procedures. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 $250 per day copayment for outpatient surgery. You have been asked to pay two $250 copayments for two separate cataract procedures. The cataract procedures fall within the outpatient surgery 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 2 cataract procedures (66984) provided August 11, 2020 and August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for retainer crowns (D6750 x2, D6751 x2), pontic (D6240, D6241), and core buildups (D2950 x2) provided on April 14, 2021.
You asked the Plan to pay an additional amount for retainer crowns, pontic, and core buildups. You say that you were not aware that you had a $1000 annual benefit maximum. The Plan denied your request. The Plan says the services at issue are covered benefits, however the benefit maximum had already been met before this date.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of retainer crowns, pontic, and core buildups have not been met. Specifically, the record shows that you had exhausted your dental benefit maximum. Therefore, we decided that the Plan does not have to pay an additional amount for retainer crowns (D6750 x2, D6751 x2), pontic (D6240, D6241), and core buildups (D2950 x2) provided on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 12, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for patients with suspected or documented cardiovascular disease.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request is for an advanced genetic cardiovascular risk assessment panel. The enrollee does not have multiple treatment options to decide on besides statin medication and lifestyle modification. Genetic testing in this clinical situation had not been shown to lead to a significant change in treatment or lead to significantly improved overall outcomes. Therefore, this request for genetic advanced cardiovascular risk assessment panel will be considered not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided on August 10, 2020.
You asked the Plan to pay for Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older
(99152). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no documentation of an independent trained observer assisting in the monitoring of the enrollee.
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 99152 is not supported in the medical record. Specifically, there is no documentation of the presence of an independent rained observer to assist in the monitoring of the enrollee's level of consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage of Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older (99152) have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided on August 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron tablet, 4mg.
You asked the Plan to pre-approve Ondansetron. You say that the requested medication is medically necessary.
The Plan denied your request. The Plan says the only medicines that are covered under the medical benefit are
oral medicines to treat cancer or nausea after cancer treatment when administered within a certain time frame.
The Plan says that the requested medication has not been prescribed for these treatments and is being given for
a period that exceeds the time frame. The Plan also says that the requested medication may fall under the Part
D Medicare benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Ondansetron tablet, 4mg.