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

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the Medicare rules 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 the DME. Our physician reviewer found a home ventilator is not medically necessary. Although arterial blood gas data are not provided, this enrollee appears to have chronic hypoxic and hypercapnic respiratory failure, possible due to a combination of COPD and obesity hypoventilation syndrome (OHS), although pulmonary function tests are not provided. The enrollee has improved when treated with BiPAP acutely in the hospital. A previous sleep study showed successful treatment of the disordered breathing with BiPAP. However, it appears from the clinical notes, the enrollee is not using the BiPAP consistently at home. Certain BiPAP devices can provide the average volume assured pressure support (AVAPS) mode that is ordered, and Medicare does not cover a ventilator when used as BiPAP. However, if the enrollee is not using BiPAP, the enrollee is not likely to use the ventilator either. The denial is upheld. 

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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total of 32 additional occupational therapy (OT) sessions.
You asked the Plan to pre-approve the additional OT services. You say that it is felt that the requested number of OT sessions is appropriate and necessary. The Plan denied your request. The Plan says more than four OT sessions are not supported as medically necessary by the records provided.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional OT services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The records do not demonstrate that the unique skills of a professional occupational therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The documentation does not reveal evidence of functional deficits or inability to perform daily living activities. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 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 additional OT services have not been met. Therefore, we decided that the Plan does not have to pre-approve a total of 32 additional occupational therapy (OT) sessions.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on July 27, 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 procedure code 15733 is not supported.

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 15733 is muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae). 

We find that CPT code 15733 is not supported in the medical record. Specifically, the operative report does not contain documentation of a muscle, myocutaneous, or fasciocutaneous flap from the head and neck. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for direct admit to observation services (G0379) provided April 27, 2021.
You asked the Plan to waive the copayment for the observation services. You say that you don't think you should be charged as it was related to the surgery you had done. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $200 copayment for outpatient hospital observation services. You have been asked to pay $200 copayment for the observation services. The observation services fall within the Outpatient hospital observation 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 direct admit to observation services (G0379) provided April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110), evaluation (D0120), x-rays (D0272) and filling (D2331) provided on March 25, 2021, and March 26, 2021.

You asked the Plan to pay for the dental services. You say that you did not realize that routine dental care was no longer covered by the Plan. The Plan denied your request. The Plan says preventative dental services are not covered without purchasing an optional supplemental benefit.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The record also includes a copy of the Plan's Annual Notice of Changes for 2021, which does include information regarding the changes to the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110), evaluation (D0120), x-rays (D0272) and filling (D2331) provided on March 25, 2021, and March 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to be functioning at/near his baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point, as a practical matter, can be provided at a lower 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine and immunization administration provided on November 24, 2020.
You asked the Plan to pay for the Tdap vaccine (90715) and immunization administration (90471). You say that your doctor wanted you to have the vaccine so you did. The Plan denied your request. The Plan says this vaccine is not covered under your Medicare Part B drug benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine (90715) and immunization administration (90471). The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine (90715) and immunization administration (90471). Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine and immunization administration provided on November 24, 2020.
Benefits for the Tdap vaccine (90715) and immunization administration (90471) 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 the laboratory services provided on February 9, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on March 24, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 the physician services provided on March 24, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion supplies rendered on May 22, 2020 to May 31, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the infusion supplies rendered on May 22, 2020 to May 31, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 1, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from July 14, 2020 through September 17, 2020. The Plan says, per Medicare guidelines, the provider needs to bill Original Medicare for the services rendered on September 1, 2020.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 29, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that this was an emergency and there was no time to request a referral. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. The medical record shows the visit was a follow-up evaluation. 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 the office visit provided on December 29, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the tendon sheath incision (26055) provided on January 27, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $250 per day for outpatient procedures and services, including but not limited to, diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.
You have been asked to pay a $250 copayment for the outpatient surgery provided. 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 tendon sheath incision (26055) provided on January 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MAZE procedure and Convergent hybrid procedure (thoracoscopic off-pump surgical ablation) (CPT code(s): 33266, 33999) and two (2) inpatient bed days, for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says neither Medicare nor the enrollee's Medicare Advantage health plan covers this request. The Plan states the medical studies haven't proven that the service(s) or procedure(s) is helpful for treatment of the enrollee's health problem.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the case file does not contain documentation of this enrollee's burden of atrial fibrillation. It is not documented that the enrollee has failed treatment with antiarrhythmic medication or catheter-based therapy. The documentation in the case file is insufficient to demonstrate that the MAZE procedure and Convergent hybrid procedure are medically reasonable and necessary for the enrollee at this time. We believe it is reasonable to attempt to surgically ablate atrial fibrillation (AF) in carefully selected patients with a high burden of AF. Most of these patients will have been referred for cardiac surgery for another reason, such as significant valvular or coronary heart disease. It is uncommon for patients without an indication for open heart surgery to be referred for a surgical ablative procedure. Stand-alone surgical ablation for symptomatic AF without structural heart disease is reasonable in patients who have failed a class I or III antiarrhythmic medication or catheter-based therapy. 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 pre-approve the MAZE procedure and Convergent hybrid procedure (thoracoscopic off-pump surgical ablation) (CPT code(s): 33266, 33999) and two (2) inpatient bed days, for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on August 1, 2020 by an out-of-network provider.
You asked the Plan to pay for the therapeutic procedure (97110), manual therapy (97140) and electrical stimulation (G0283). You say that the enrollee was treated in good faith and provided the medical care he required. The Plan denied your request. The Plan says prior authorization was not requested as required.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on August 1, 2020 by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests (D0460) and pulpal debridement, primary and permanent teeth (D3221) provided March 19, 2021.
You asked the Plan to pay for the pulp vitality tests and pulpal debridement. You say that the services should be covered because your benefits states that diagnostic services are covered. The Plan denied your request. The Plan says these services are not covered under your benefits.
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 pulp vitality tests (D0460) and pulpal debridement, primary and permanent teeth (D3221) provided March 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure therapy (CPAP)
power pack.
You asked the Plan to pre-approve a CPAP power pack. You say that you need a battery back up for your
CPAP. The Plan denied your request. The Plan says the requested item is not a covered benefit.
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 continuous positive airway pressure therapy (CPAP)
power pack.