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

We decided that the Plan does not have to pre-approve Promethazine.
You asked the Plan to pre-approve Promethazine. You say that the drug will be used on an as needed basis. The Plan denied your request. The Plan says Promethazine to be administered at home is not covered under the 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 Promethazine.
Benefits for Promethazine 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 group 3 power wheelchair and accessories for the
enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says a repairs vs replacement quote is needed to determine the most economical course of
action.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation
from February notes that the last recorded weight was 300 pounds. The power of attorney states that the
enrollee gained weight, and cannot fit in the current wheelchair, and needs a new power wheelchair. The
K0861 includes up to 300 lb. weight capacity, however the documentation does not reveal a recent physician
medical progress note indicating an objective weight measurement that would be necessary in order to provide
the most appropriate mobility device for this enrollee. The K0861 cannot be considered appropriate for the
enrollee's medical needs without an updated objective weight.
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 a group 3 power wheelchair and accessories for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received from June 2, 2020, to July 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you do not have a referral 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 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 the chiropractic services you received from June 2, 2020, to July 10, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the personal care services (T1019) provided August 7, 2020.

You asked the Plan to pre-approve the personal care services. You say that since you were not notified on the coverage/contract change or that the authorization ended, you are asking for reconsideration of the previous decision and allow coverage for these claims. The Plan denied your request. The Plan says this service is not a covered benefit.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve the personal care services (T1019) provided August 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the 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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex device at the L3-L4 and L4-L5 level is not medically reasonable or 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November
1, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you never requested the
services and feel that they were unnecessary. 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 $265
copayment for ambulance services.

You have been asked to pay a $265 copayment for ambulance services. Ambulance services fall within the
ambulance services 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 ambulance services
provided on November 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for inhalation of nitrous oxide/analgesia (D9230), and the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) received October 27, 2020 from the opt-out provider.
You asked the Plan to pay for the dental services (D9230, D7210). You say that the requested services were necessary. The Plan denied your request. The Plan says the provider in this case was opted out of Original Medicare on the date of service.
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. The Plan has submitted evidence that the provider was opted out of Original Medicare on this date of service. Therefore, we decided that the Plan does not have to pay for inhalation of nitrous oxide/analgesia (D9230), and the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) received October 27, 2020 from the opt-out provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the continued skilled nursing stay provided from November 1, 2020, to November 4, 2020 by an OON provider.
You asked the Plan to pay for the continued skilled nursing stay. You say that the services were medically necessary. The Plan denied your request. The Plan says that the enrollee's other health plan has the primary responsibility for this claim.
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. The enrollee was effective under a new plan beginning November 1, 2020, and this new Plan should cover these services. There was no evidence provided by the Plan supporting that the payer at the time of admission to the skilled nursing facility must pay until discharge. Therefore, we decided that the Plan has to pay for the continued skilled nursing stay provided from November 1, 2020, to November 4, 2020 by an OON provider.
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided December 17, 2020 to December 28, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services rendered were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the enrollee to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was admitted with chronic leg wounds and to undergo a right lower extremity angiogram with possible intervention. The enrollee was evaluated by Nephrology and required IV hydration. The enrollee also had a urinary tract infection requiring IV antibiotics. The enrollee received wound care. The enrollee's conditions were treated, stabilized, and improved. The documentation supports that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. Therefore, the enrollee met criteria for the services rendered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided December 17, 2020 to December 28, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical first radiographic image (D0220), the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), and the unspecified preventive procedure, by report (D1999) received November 10, and November 18, 2020 from the out-of-network provider.

You asked the Plan to pay for the dental services. You say that the claim should be covered fully by the Plan. The Plan denied your request. The Plan says services received out-of-network are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are in excess of those covered under this benefit. The requested services were received out-of-network. The Plan contract states that if you receive covered services out-of-network you must pay 100% of the cost. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical first radiographic image (D0220), the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), and the unspecified preventive procedure, by report (D1999) received November 10, and November 18, 2020 from the out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 19, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on October 18, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) suspension sleeve (L2397) provided October 2, 2020.
You asked the Plan to pay for the orthosis. You say that you trust that the verification provided will be deemed sufficient to allow the plan to verify the claims at issue and to remit payment for the pending claims as soon as possible. The Plan denied your request. The Plan says there is no claim in the enrollee's claim history from the prescribing provider on the service date. There are no claims on file with the ordering physician listed in the enrollee's claims history from 2019 to present. The enrollee did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed.
Medicare has specific coverage criteria for each type of orthosis. Based on the records provided, the enrollee did not meet the criteria for the orthosis provided. There is no claim in the enrollee's claim history from the prescribing provider on the service date. There are no claims on file with the ordering physician listed in the enrollee's claims history from 2019 to present. The enrollee did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) suspension sleeve (L2397) provided October 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on November 18, 2019.

You asked the Plan to pay for the therapeutic procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation submitted indicates that the services were performed by a physical therapist in a home health or hospice setting. This means there is a more appropriate code to be billed for these services. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Rifton Tram (E1399).
You asked the Plan to pre-approve a Rifton Tram. You say that the requested item is necessary for your care. The Plan denied your request. The Plan says the requested item is not a benefit of Medicare or the Plan.
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 a Rifton Tram. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested device does not serve a primary medical need. The requested device is not proven to be more safe and effective for your condition than similar separate medical devices that can serve the same 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 Rifton Tram have not been met. Therefore, we decided that the Plan does not have to pre-approve a Rifton Tram (E1399).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 23, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 laboratory services provided on July 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the 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 coded 99072 provided from December 23, 2020 to December 30, 2020.
You asked the Plan to pay for the 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. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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 find that CPT code 99072 is not supported in the medical record. Specifically, this code was established to report additional practice expenses incurred during a Public Health Emergency (PHE), including supplies and additional clinical staff time. This code is a bundled only procedure is not separately payable. Based on this information, we decided that Medicare rules for coverage of the 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 have not been met. Therefore, we decided that the Plan does not have to pay for the 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 coded 99072 provided from December 23, 2020 to December 30, 2020.