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

We decided that the Plan does not have to pre-approveAdcirca.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not 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 pre-approveAdcirca.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by the EMS on August 20, 2019.You asked the Plan to pay forthe ambulance services. You say that the nurse you called suggested to call for this service.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 20, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by the EMS on August 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by you on April 13, 2020.You asked the Plan to pay forthe ambulance services. You say that you were following the COVID executive order for treatment in place.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 13, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by you on April 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on February 6, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 6, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forsupplies for a continuous glucose monitor (K0553) provided July 7, 2020.You asked the Plan to pay forthe supplies. You say that the items were medically necessary.The Plan denied your request. The Plan says the documentation does not support the services billed.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid signed order for the item, or medical records to support medical necessity of the continuous glucose monitor supplies. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forsupplies for a continuous glucose monitor (K0553) provided July 7, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 26, 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 May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unspecified preventive service (D1999) provided on June 10, 2020.You asked the Plan to pay forthe unspecified preventive service. You say that your appointment in May was canceled due to Covid-19. You say that you were in severe pain. You also say that the services you received were medically necessary.The Plan denied your request. The Plan says unspecified preventive service is not listed as a covered services.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 forthe unspecified preventive service (D1999) provided on June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital bed provided on October 15, 2019, by an out-ofnetwork
(OON) provider.

You asked the Plan to pay for the provided services. You say that you have a hard time sleeping without an
adjustable bed. The Plan denied your request. The Plan says the provider is not listed as an acceptable provider.

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 provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the items 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 hospital bed provided on October 15, 2019, 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 short-latency somatosensory evoked potential study, the
continuous intraoperative neurophysiology monitoring, and the electroencephalogram (EEG) services provided
on May 9, 2019.

You asked the Plan to pay for the short-latency somatosensory evoked potential study, the continuous
intraoperative neurophysiology monitoring, and the electroencephalogram (EEG) services. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were
submitted untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for the short-latency somatosensory evoked potential study, the continuous
intraoperative neurophysiology monitoring, and the electroencephalogram (EEG) services was not filed until
August 11, 2020. This means that more than one calendar year from the date of service had passed before a
claim was filed.

Therefore, we decided that the Plan does not have to pay for the short-latency somatosensory evoked potential
study, the continuous intraoperative neurophysiology monitoring, and the electroencephalogram (EEG)
services provided on May 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services provided on July 21, 2020, by an
out-of-network provider.

You asked the Plan to pre-approve the medical services. You say that the claim should be paid. The Plan
denied your request. The Plan says there was no prior authorization obtained for the services billed.

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 items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the medical services provided on July 21, 2020, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the remote monitoring of physiologic parameters provided
on April 23, 2020.

You asked the Plan to pay for the remote monitoring of physiologic parameters. You say that the Plan should
pay this claim. The Plan denied your request. The Plan says the billed service cannot be verified.

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 99453 is Remote monitoring of physiologic parameter(s)
(e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use
of equipment and the CPT Code Manual definition of code 99454 is Remote monitoring of physiologic
parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with
daily recording(s) or programmed alert(s) transmission, each 30 days.

We find that CPT code 99453 and 99454 are not supported in the medical record. Specifically, the
documentation submitted did not include documentation of remote monitoring, set-up or patient education on
use of the equipment. Based on this information, we decided that Medicare rules for coverage of the remote
monitoring of physiologic parameters have not been met. Therefore, we decided that the Plan does not have to
pay for the remote monitoring of physiologic parameters provided on April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulatory detoxification services (H0014) provided December 17, 2019 to December 18, 2019.

You asked the Plan to pay for the ambulatory detoxification services. You say that the services were medically necessary. The Plan denied your request. The Plan says the CPT code billed is not eligible for payment.

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 H0014 is not supported in the medical record. Specifically, this CPT code is marked with a status indicated of "I" and is invalid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the ambulatory detoxification services have not been met. Therefore, we decided that the Plan does not have to pay for ambulatory detoxification services (H0014) provided December 17, 2019 to December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 10, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says screening tests are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 10, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided on January 31, 2020.

You asked the Plan to pay for the hospital services. You say that you would like reconsideration because the
member was not enrolled in hospice on this date of service. The Plan denied your request. The Plan says 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.

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 hospital services provided on January 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that 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 IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you are not shown to currently require fifteen hours per week of rehabilitative services and regular physician evaluation. You may benefit from a formal diagnostic work-up of your apparently acute weakness, after which your needs can be more clearly defined. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on June 26, 2020 by an OON provider.You asked the Plan to pay forthe periodic oral evaluation and prophylaxis. You say that you are covered for both in-network and out-of-network dental services. You also say that you are entitled to reimbursement for the difference.The Plan denied your request. The Plan says the cost share was applied correctly per your plan benefits. The Plan also says that cost-sharing is a contractual obligation of the Plan and cannot be waived.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, you are responsible for the difference between the billed amount and allowed amount.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on June 26, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe excision of a benign lesion, first 15 minutes of deep sedation/general anesthesia, each subsequent 15 minute increment of deep sedation/general anesthesia, and therapeutic parenteral drug provided on June 18, 2020.You asked the Plan to pay forthe excision of a benign lesion, deep sedation/general anesthesia services, and therapeutic parenteral drug. You say that you have been with this provider for a long time. You also say that the treatment was essential because your dentist noticed a lesion in your mouth.The Plan denied your request. The Plan says theservices were rendered by a provider who does not accept Medicare assignment. The Plan also says that the treating provider has opted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay forthe excision of a benign lesion, first 15 minutes of deep sedation/general anesthesia, each subsequent 15 minute increment of deep sedation/general anesthesia, and therapeutic parenteral drug provided on June 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that 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 IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Supartz injection.
You asked the Plan to pre-approve the Supartz injection. You say that you would like reconsideration because your knees are in bad shape and you are in a lot of pain. The Plan denied your request. The Plan says you do not meet criteria for this service.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the Supartz injection. Our reviewer says that there is no specific clinical rationale for the requested Supartz injection. The documentation does not support that Supartz is safe and effective for you. Our physician reviewer found there is no documentation provided indicating that you had an inadequate response to conservative non-pharmacologic therapy. There is no submitted documentation of referral or orders for physical therapy or DME; and no submitted documentation of your participation in physical therapy or use of DME. There is no documentation indicating that you had an inadequate response to analgesics (for example, acetaminophen) and non-steroidal anti-inflammatory drugs. There is no submitted documentation of actual NSAID or other oral analgesic use. 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 Supartz injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Supartz injection.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on March 25, 2020.
You asked the Plan to pay for the paramedic intercept services. You say that the ambulance company called the
paramedics. The Plan denied your request. The Plan says this item is not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances.
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area.
The paramedic intercept services at issue in this appeal were not furnished in a rural area and there is no
contract between the provider and the ambulance service. Therefore, we decided that the Plan does not have to
pay for the paramedic intercept services provided on March 25, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient mental health care.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the stay is medically
necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient psychiatric hospital services.
Our physician reviewer found it is medically necessary and reasonable to have psychiatric care provided at the
acute inpatient level of care rather than a lower level of care. The provider outlined specific individualized
goals for the enrollee. This enrollee did appear to require inpatient mental health treatment as the enrollee was a
danger to themselves and the plan was reasonably expected to improve the enrollee's condition for which the
enrollee was hospitalized. The records demonstrated physician evaluation and supervision. Based upon review
the records provided for the admission of this patient, the enrollee meets criteria for acute inpatient mental
health treatment because the enrollee was to receive active treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided
that the Plan has to pre-approve inpatient mental health care.