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

We decided that the Plan has to pre-approve in-network tertiary specialist services.
You asked the Plan to pre-approve tertiary level of care. You say that the requested in-network tertiary level of care specialist is medically necessary. The Plan denied your request. The Plan says that the requested in-network tertiary level of care specialist is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve tertiary level of care. Our reviewer says that the requested in-network tertiary level of care specialist is medically necessary. Our physician reviewer found this is a situation where multiple specialties and medical services will be involved with this enrollee's care; her deafness likely makes it more challenging to communicate with the enrollee and makes it important for the various services that will be involved with her care to be able to communicate with each other easily. An example is the potential for using an SGLT2 inhibitor by endocrine to control blood glucose levels and help her cardiovascular risk. Another would be to have social work help her with better food options with endocrine and dietary input. Hence a system where all providers have easy access to all records seems critical and this would be provided in the requested tertiary 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 tertiary level of care have been met. Therefore, we decided that the Plan has to pre-approve in-network tertiary specialist services.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 1, 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 the testing is 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, a cardiovascular risk assessment panel, 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 June 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and
services.
You asked the Plan to pay for IRF care. You say that the enrollee needs IRF care. The Plan denied your
request. The Plan says the enrollee can be treated at a lower level of 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 in the Medicare rules section.
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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
has a past medical history of stroke and is living at home receiving physical therapy for ongoing weakness. His
medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical record
supports a need for physical and occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation
therapy program provided in an IRF.
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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the $50 copayment charged for medical supplies provided on November 12, 2020.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on your Plan contract agreement.
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 $50 copayment for medical supplies. 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 $50 copayment charged for medical supplies provided on November 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMems device.
You asked the Plan to pre-approve a CardioMems device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 CardioMems device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety of this device. It is not clear that the CardioMEMS device is medically reasonable and necessary for you. The documentation does not support that you will be enrolled in a Medicare-approved medical research study. 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 CardioMems device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMems device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 12, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 physician's services. 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 physician's services provided on March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on August 26, 2020.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that it is not your fault that the code was changed. You say the service was preventive and it should have been covered. The Plan denied your request. The Plan says you are not being charged the denied codes and have been charged the correct cost-sharing 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 $50 copayment for diagnostic mammography at an out-of-network specialist's office. You have been asked to pay a $50 copayment for the diagnostic mammogram. The diagnostic mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows a diagnosis of benign mammary dysplasia which makes the mammogram diagnostic in nature. 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 diagnostic mammogram provided on August 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 19, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation does not show how the enrollee was referred to this provider or whether this testing was medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on August 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transport from dialysis to residence provided on May 20, 2020.
You asked the Plan to pay for the non-emergent ambulance transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee appears to be able to sit in a wheelchair or recliner therefore alternatives to transport may include a wheelchair van or a private vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. The record shows the enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. The enrollee could have been safely transported by another type of vehicle. You did not request prior authorization. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport from dialysis to residence provided on May 20, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the interpretation and report of an ECG (93010) provided on July 28, 2020.
You asked the Plan to pay for the interpretation and report of an ECG.. You say that you would like reconsideration because this is for the interpretation of an ECG and should not be considered with any other procedure. The Plan denied your request. The Plan says that CPT code 93010 is a column II code to another service that was billed on the same date.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that MACs subject all line items for the same beneficiary, same national provider identifier (NPI), and same date of service to national correct coding initiative (NCCI) edits. We find that CPT code 93010 is supported in the record. Specifically, the column I and column II codes addressed were rendered by separate providers. NCCI edits do not apply to services rendered by different providers. Based on this information, we decided that Medicare rules for coverage of the interpretation and report of an ECG. have been met. Therefore, we decided that the Plan has to pay for the interpretation and report of an ECG (93010) provided on July 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 23, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from October 2, 2020, through October 5, 2020.
You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The Plan says prior authorization should have been obtained prior to the services being rendered.
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 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 a behavioral health inpatient admission provided from October 2, 2020, through October 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for excision procedures on the leg (tibia and fibula) and ankle joint (27630) repair, revision, and/or reconstruction procedures on the leg (tibia and fibula) and ankle joint (27698) provided July 28, 2020.
You asked the Plan to pay for the surgical procedures. You say that the medical records should support the necessity of the service in dispute. The Plan denied your request. The Plan says the procedure codes are not documented in the operative report narrative or is inclusive to a more appropriate CPT code.
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 codes 27630 and 27698 are not supported in the medical record. Specifically, in the operative report did not include documentation of a secondary repair of a disrupted collateral (Watson-Jones procedure) ligament of the ankle. For CPT code 27630, the operative report did not include documentation of an excision of lesion of tendon sheath or capsule (cyst or ganglion) of the leg and/or ankle. Based on this information, we decided that Medicare rules for coverage of the surgical procedures have not been met. Therefore, we decided that the Plan does not have to pay for excision procedures on the leg (tibia and fibula) and ankle joint (27630) repair, revision, and/or reconstruction procedures on the leg (tibia and fibula) and ankle joint (27698) provided July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure and crown provided on October 13, 2020 by an OON provider.
You asked the Plan to pay for the preventive procedure and crown. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services were rendered by an OON provider.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the preventive procedure and crown provided on October 13, 2020 by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for all open procedures on lower one-third of femur provided on September 14, 2020.
You asked the Plan to pay for the anesthesia. You say that this service was provided on an emergency basis. The Plan denied your request. The Plan says you were under hospice care on this date of service. The Plan also says that Original Medicare continues to pay for services furnished after the revocation or expiration of your hospice election until the first day of the month after the hospice election has been revoked or terminated.
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 September 10, 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 the anesthesia for all open procedures on lower one-third of femur provided on September 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says this stay meets criteria for observation level of care and the admitting physician admitted this patient under observation.

The Plan must follow Medicare rules. The rules say that the order for inpatient admission must be present in the medical record.

We looked at the file and Medicare rules. The physician order was for observation care. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a post and core (D2952).
You asked the Plan to pre-approve a post and core. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not covered under the benefit plan.
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 pre-approve a post and core (D2952).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Pepcid tablet, Ondansetron tablet, and Ticagrelor tablets provided on April 1, 2020.
You asked the Plan to pay for the Pepcid tablet, Ondansetron tablet, and Ticagrelor tablets. You say that you would like to be reimbursed for these drugs. The Plan denied your request. The Plan says the drugs at appeal are self-administered drugs. The Plan also says that self-administered drugs are not Part B covered.
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 pay for the Pepcid tablet, Ondansetron tablet, and Ticagrelor tablets provided on April 1, 2020.
Benefits for the Pepcid tablet, Ondansetron tablet, and Ticagrelor tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a portable oxygen concentrator (E1392) provided on September 15, 2020.
You asked the Plan to pay for a portable oxygen concentrator. You say that the requested item should be covered as you need the oxygen. The Plan denied your request. The Plan says rules for payment have not been met because the provider does not participate with Medicare.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested durable medical equipment have not been met. Specifically, the services at issue were provided by a provider that appears to not be certified for Medicare. The provider at issue did not come up on the Medicare.gov search for Durable Medical Equipment suppliers serving your area. There was no documentation supplied by the provider to verify that they are certified by Medicare. Therefore, we decided that the Plan does not have to pay for a portable oxygen concentrator (E1392) provided on September 15, 2020.