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

We decided that the Plan does not have to pay for ambulance services (A0429) provided to the enrollee on March 5, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records indicate that the enrollee was pronounced dead after the ambulance was called.
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 Healthcare Common Procedure Coding System (HCPCS) code
A0429 is "Ambulance service, basic life support, emergency transport (bls-emergency)." We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0429) provided to the enrollee on March 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 20, 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the first day of the month following the month in which hospice was revoked or discharged.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 November 20, 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 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 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a white cane (A9270).
You asked the Plan to pre-approve a white cane. You say that you are appealing the denial of the white cane because you have no vision on the right side of both eyes and your doctor requests equipment to improve your quality of life so you can have more mobility and independence. The Plan denied your request. The Plan says a white cane for use by a blind person is an identifying and self-help device and is not covered.
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 white cane (A9270).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance transportation services provided on December 19, 2019.

You asked the Plan to pay for the air ambulance transportation. You say that you would like reconsideration because the member was taken to the nearest facility which was able to provide the necessary services for the member. The Plan denied your request. The Plan says the air ambulance services do not meet the requirements for approval.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the air ambulance transportation. Our reviewer says that there was no contraindication to other means of transport, namely ground ambulance services or stretcher van and the records did not show that the member was unstable or would be at risk for using ground transport to the local hospital. Our physician reviewer found the record indicates that the shorter distance would have been to the local hospital. 

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 air ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance transportation services provided on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on March 18, 2021.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on March 18, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the arteriographic study (36247, 36248, 75726, 75774, and 77290) provided on January 25, 2021.
You asked the Plan to pay for codes 36247, 36248, 75726, 75774, and 77290. You say that the medical records support the billing of codes 36247, 36248, 75726, 75774, and 77290. The Plan denied your request. The Plan says that the medical records do not support the billing of codes 36247, 36248, 75726, 75774, and 77290.
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 36247 is Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family. The definition of code 36248 is Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate). The definition of code 75726 is Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation. The definition of code 75774 is Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure). The definition of code 77290 is Therapeutic radiology simulation-aided field setting; complex. 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 codes 36247, 36248, 75726, 75774, and 77290. Our reviewer says that the medical records support the billing of codes 36247, 36248, 75726, 75774, and 77290. Our physician reviewer found review of the angiographic procedure done on 1/25/21 supports each code which has been billed. The enrollee had aortogram followed by celiac arteriogram followed by selective catheterization of the main hepatic artery and then 4 peripheral branches. Finally, Technetium 99m MAA was injected to look for shunting to the lungs. These procedures were all well documented in the angiogram report and should be reimbursed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 36247, 36248, 75726, 75774, and 77290 have been met. Therefore, we decided that the Plan has to pay for the arteriographic study (36247, 36248, 75726, 75774, and 77290) provided on January 25, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says the enrollee has not tried and failed Monovisc and Orthovisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Gel-One. Our physician reviewer found that the enrollee has a history of bilateral osteoarthritis of the knees and history of low back pain secondary to lumbar spondylosis. The Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. The enrollee has not tried Orthovisc and Monovisc. The documentation does not outline contraindications or reasons these medications were not considered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for primary closure of a sinus perforation (D7261) provided on February 9, 2021.

You asked the Plan to pay for primary closure of a sinus perforation. You say that you were not aware that the service would not be covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

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 primary closure of a sinus perforation (D7261) provided on February 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0457) provided to the enrollee on March 18, 2021.
You asked the Plan to pay for the back brace. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a back brace (L0457) provided to the enrollee on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99153) provided to the enrollee on August 31, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service was inappropriate for this procedure.
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 99153 is "Moderate sedation services provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes of intra-service time (List separately in addition to code for primary service)." We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found per the
CMS guidelines "Billing for moderate sedation services (CPT Codes 99151 or 99152) represents the first 15 minutes of service. All physician work occurs during that first 15 minutes. Usually thereafter, the physician is engaged in performing the procedure, and a nurse will monitor the patient. CPT 99153 has no physician work associated with it and is therefore a technical component only code (PC/TC 3 ). When billed in a facility setting it is not payable to the physician but may be paid to the facility. When billed in the office it is payable to the physician." We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided to the enrollee on August 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the patient is not safe to return home. The Plan denied your request. The Plan says that the records do not support the need for daily therapy on an inpatient basis. 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses and lenses (V2025, V2783), sphere lenses (V2100) and polarization (V2762) provided on April 7, 2021.
You asked the Plan to pay for eyeglasses, lenses and polarization. You say that the claim was denied incorrectly, and you are seeking reconsideration. The Plan denied your request. The Plan says the services must be obtained by an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when it is obtained through one of the Plan's in-network providers. We looked at the file and the Plan's rules. These services are not covered if performed by a provider that is not part of the Plan's network. The records show that the services at issue were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses, lenses and polarization have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses and lenses (V2025, V2783), sphere lenses (V2100) and polarization (V2762) provided on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and the comprehensive oral evaluation (D0150) received May 3, 2021.
You asked the Plan to pay for the panoramic radiographic image and the comprehensive oral evaluation. You say that the Plan should cover the requested services. The Plan denied your request. The Plan says the requested services are only covered for one procedure every three plan years.
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 only covered under this benefit for one procedure each, every three years. The Plan has provided evidence that the requested procedures were last covered on March 13, 2019. When you received the requested services on May 3, 2021 your benefit was exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and the comprehensive oral evaluation (D0150) received May 3, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 additional home health physical therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says the approved visits will allow the nurse to review medication management.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 visits. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found no required skilled nursing services are identified. The documentation does not support that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 16 additional home health physical therapy visits for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation by stretcher.
You asked the Plan to pre-approve transportation by stretcher. You say that you are unable to be transported in a car or van or cab. The Plan denied your request. The Plan says rules for routine transportation have not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 12 one-way trips per calendar year. However, the benefit does not cover transportation by stretcher.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation by stretcher.