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

We decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) rendered on August 30, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 93042 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 93042 is rhythm ECG, 1-3 leads; interpretation and report only. We find that CPT code 93042 is not supported in the medical record. Specifically, there is no documentation of an interpretation and report of a rhythm ECG. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) rendered on August 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a LTACH for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says it would be inappropriate to transfer to LTACH at this time.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a LTACH for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on May 9 to July 9, 2020.

You asked the Plan to pay for a neuromuscular stimulator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of durable medical equipment (DME) may not contact an individual by telephone regarding the furnishing of a covered item to the individual except in certain situations outlined under "Medicare rules." 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a neuromuscular stimulator have not been met. Specifically, the Plan has attested that this enrollee was contacted via an unsolicited phone call regarding provision of the item at issue. As such, no payment may be made for this item. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on May 9 to July 9, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses provided on August 6, 2020.
You asked the Plan to pay for the progressive lenses. The Plan denied your request. The Plan says based on Medicare guidelines; the progressive glasses lenses (V2781) do not meet the requirements for approval. Under Medicare guidelines, your request is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover progressive lenses.
We looked at the file and the Medicare rules. Medicare does not cover progressive lenses. Therefore, we decided that the Plan does not have to pay for the progressive lenses provided on August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on December 29, 2020.
You asked the Plan to pay for the dental services. You say that you dislodged a crown. You say that your dentist advised that it needs to be replaced. You say that you do not understand how this claim could be denied since you had no other choice but to see your doctor. The Plan denied your request. The Plan says limited oral evaluation and periodic exam share a frequency limit of 2 per calendar year. The Plan says that the frequency limit has been exceeded. The Plan says that 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limit has been exceeded.
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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for periodic oral exams that you received on January 9, 2020, and July 30, 2020. This service shares a frequency limit with limited oral evaluations and therefore has been exhausted. The record also shows that the Plan paid for a periapical x-ray that you received on July 30, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on December 29, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Computed Tomography (CT) angiography.
You asked the Plan to pre-approve CT angiography. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this test is correct, because this test is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 CT angiography. Our reviewer says that the enrollee meets the criteria for the requested CT scan. Our physician reviewer found the enrollee has a Heartmate 3 and has had drive-line infection. He is undergoing transplant evaluation. The documentation shows that the requested test is medically reasonable and necessary in an enrollee with implanted artificial heart. This test is recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT angiography have been met. Therefore, we decided that the Plan has to pre-approve Computed Tomography (CT) angiography.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 1, 2020, through December 7, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says that the enrollee could have been treated at an alternate level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient 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 that the enrollee is a 34-year-old woman who presented with altered mental status and hypoglycemia. At issue is whether inpatient services for the enrollee are covered under Medicare rules. If the patient requires medically necessary hospital care that is expected to span 2 or more midnights, then inpatient admission is generally appropriate. "Span 2 or more midnights" includes time spent in the ED and/or observation, as well as time spent at another hospital prior to transfer to the current facility. If the physician expects the patient's medically necessary treatment to span less than 2 midnights and not involve services designated by CMS as inpatient-only, it is generally appropriate to treat the patient in outpatient status. The decision to admit as an inpatient should generally be based on the treating physician's reasonable expectation of a length of stay spanning 2 or more midnights, taking into account complex medical factors that must be documented in the medical record. In this case, the enrollee is also on dialysis with a history of congestive heart failure and presented with a temperature of 100.2 F. She was originally admitted for observation stay at
11:58 p.m. However, subsequent documentation, supported by the documentation indicates that the enrollee was admitted for a minimum two day stay based upon the diabetes, end stage renal disease, anemia, and altered mental status as complex comorbidities given the presenting signs and symptoms. The decision to admit was based upon the treating physician's reasonable expectation of a length of stay spanning 2 or more midnights, taking into account complex medical factors that must be documented in the medical record. The elements of the coverage rule are satisfied.
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 from December 1, 2020, through December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis and the miscellaneous dme supply provided on October 6, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis and the miscellaneous dme supply. 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. 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 proof of delivery for the supplies provided in this case. Review of the file shows that the documentation submitted does not include an itemized shipping/billing invoice to indicate the specific supplies for the billed date of service. 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 for the lumbar-sacral orthosis and the miscellaneous dme supply provided on October 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have a diagnosis of osteoporosis. You have not tried and failed the Plan's required drug, oral bisphosphonates. The records do not show that the required drug would be less effective or have adverse effects; therefore, Prolia is not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on May 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member must use network providers for medical services unless the services are urgent, emergent, or approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on May 6, 2020 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 office visit (99205) provided on October 28, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (99205) provided on October 28, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency treatment of dental pain (D9110), and an intraoral periapical radiographic image (D0220) provided on December 2, 2020.
You asked the Plan to pay for emergency treatment of dental pain, and an intraoral periapical radiographic image. You say that the service was medically necessary due to pain. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for emergency treatment of dental pain (D9110), and an intraoral periapical radiographic image (D0220) provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve monitored anesthesia care (MAC) for an epidural steroid injection (ESI).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has back pain. She had a previous injection on January 12, 2021 that was performed with MAC. The record was updated to indicate that the enrollee has severe procedural anxiety as well as needle phobia. Records from 2020 were also provided that indicated the enrollee has anxiety and post traumatic care disorder. The MAC is therefore reasonable and medically necessary for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve monitored anesthesia care (MAC) for an epidural steroid injection (ESI).

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided on December 17, 2020.

You asked the Plan to pay for the ambulance transportation. The Plan denied your request. The Plan says the ambulance services are not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance transportation. Our reviewer says that the requested ambulance transportation is not medically reasonable and necessary. Our physician reviewer found that the medical records do not support the medical necessity of the use of ambulance services to transport this enrollee out of the hospital. There is no reason provided as to why the enrollee could not use the services of a wheelchair van or stretcher van. 

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 ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation provided on December 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy, for the enrollee.
You asked the Plan to pre-approve medical nutrition therapy. You say that the services are necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of medical nutrition therapy have not been met. The enrollee has problems with acid reflux, heart failure, chronic lung problems, had stomach cancer in the past. The enrollee had surgery to remove the stomach. The enrollee has problems with weight loss and has been losing weight. A feeding tube was placed to make sure the enrollee would get enough calories in the enrollee's diet. The enrollee has made changes in their diet and is trying to eat more. Medicare considers medical nutrition therapy to be reasonable and necessary when the enrollee has diabetes or kidney problems. This request cannot be approved because the enrollee does not have diabetes or kidney problems. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy, for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified adjunctive procedure (D9999) received November 2, 2020.

You asked the Plan to pay for the unspecified adjunctive procedure (D9999). You say that the requested service was necessary. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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 the unspecified adjunctive procedure (D9999) received November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 10, 2020.
You asked the Plan to pay for laboratory services. You say that you did not get a referral because of the complaint. You say that a referral from the skin cancer office rather than your primary care doctor should be sufficient. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 10, 2020.