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

We decided that the Plan has to provide coverage for the air ambulance transport provided November 28, 2020.You asked the Plan to provide coverage for the air ambulance transport. You say that the enrollee required immediate transport to a facility that could provide the necessary services.The Plan denied your request. The Plan says that transport could have been safely provided by ground ambulance.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 transport. Our reviewer says that the service is not medically necessary. Our physician reviewer found that enrollee's active pulmonary embolisms contraindicated transportation by any other means than ambulance. The documentation supports that time spent transporting by ground would have endangered the enrollee's health and that the transferring hospital did not have adequate facilities to provide the needed services for this enrollee. Therefore, the ambulance services provided November 28, 2020 were medically reasonable and 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 the air ambulance transport have been met.Therefore, we decided that the Plan has to provide coverage for the air ambulance transport provided November 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor.You asked the Plan to pre-approvean automatic blood pressure monitor. You say that you need this to keep your blood pressure in check.The Plan denied your request. The Plan says that this is not covered under Medicare for your request.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four 2D oral/facial photographic images (D0350 x4), four gingival irrigations (D4921 x4), and periodontal procedure (D4999) provided on February 16, 2021.You asked the Plan to pay forthe 2D oral/facial photographic images, gingival irrigations, and periodontal procedure. You say that you believe these services should be covered.The Plan denied your request. The Plan says these services are not covered under your dental 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 pay for the four 2D oral/facial photographic images (D0350 x4), four gingival irrigations (D4921 x4), and periodontal procedure (D4999) provided on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on December 8, 2020.You asked the Plan to pay for the surgical pathology services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services are not payable as billed.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 88305 is Level IV -Surgical pathology, gross and microscopic examination Abortion -spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy 
Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy -without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium -biopsy/tissue Polyp, cervical/endometrial Polyp, colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine,biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy.We find that CPT code 88305 is not supported in the medical record. Specifically, this code was billed with diagnosis code D12.1 (Benign neoplasm of appendix). However, code 88305 involves a level of surgical pathology and gross microscopic examination that does not include the appendix. Based on this information, we decided that Medicare rules for coverage of the surgical pathology services have not been met.Therefore, we decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - two surfaces, posterior (D2392)
provided March 3, 2021.

You asked the Plan to pay for the filling. You say that this service should be covered because you believe your
filling loosened while your dentist cleaned your teeth. The Plan denied your request. The Plan says this service
is not covered under your dental 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 the resinbased
composite - two surfaces, posterior (D2392) provided March 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary.The Plan denied your request. The Plan says the requested Vertiflex device is not medically necessary.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 Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is with low back pain and neurogenic claudication. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion device at L3-L4 andL4-L5 is not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met.Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF care.

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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found based on the documentation
provided, the enrollee no longer qualified for SNF coverage after 6/11/2021. The enrollee does not have
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of
the enrollee's condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic CGM device (K0554) with a supply allowance (K0553).You asked the Plan to pre-approve a therapeutic CGM with a supply allowance. You say that you are unable to check glucose because of neuropathy and psoriatic arthritis.The Plan denied your request. The Plan says rules for CGMs have not been met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose testing at least four times per day and use insulin with at least three daily injections. Based on this information, 
we decided that Medicare rules for coverage of a therapeutic CGM with a supply allowance have not been met.Therefore, we decided that the Plan does not have to pre-approve a therapeutic CGM device (K0554) with a supply allowance (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lenses (V2100 x2, V2781 x2), and anti-reflective coating (V2750 x2) received on February 12, 2021.
You asked the Plan to pay for lenses, and anti-reflective coating. You say that you want the Plan to pay.The Plan denied your request. The Plan says the items at issue are not covered benefits.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. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of lenses, and anti-reflective coating have not been met. Specifically, the items at issue are not covered benefits.Therefore, we decided that the Plan does not have to pay for lenses (V2100 x2, V2781 x2), and anti-reflective coating (V2750 x2) received on February 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Transurethral Waterjet Ablation of the prostate (0421T).You asked the Plan to pre-approve Transurethral Waterjet Ablation of the prostate (0421T). You say that the requested Transurethral Waterjet Ablation of the prostate (0421T) is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Transurethral Waterjet Ablation of the prostate (0421T).
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 Transurethral Waterjet Ablation of the prostate (0421T). Our reviewer says that the enrollee does not meet criteria for the requested Transurethral Waterjet Ablation of the prostate (0421T). Our physician reviewer found the enrollee is with urinary retention and metastatic prostate cancer. The urinary retention is managed with finasteride and tamsulosin. The prostate cancer is managed with Zytiga. Prostate size is 170 cc. Request is for coverage of Transurethral Waterjet Ablation of the prostate (0421T).  The enrollee does not meet the above LCD criteria for the requested Transurethral Waterjet Ablation of the prostate (0421T). Specifically, the prostate size must be 30-150 cc and age must be less than or equal to 80.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Transurethral Waterjet Ablation of the prostate (0421T) have not been met.Therefore, we decided that the Plan does not have to pre-approveTransurethral Waterjet Ablation of the prostate (0421T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 10, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 the subsequent nursing facility care provided on February 10, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).You asked the Plan to preapprove the CGM. You say that the CGM should be covered.The Plan denied your request. The Plan says the coverage criteria have not been met in full.The Plan must follow Medicare rules. Medicare rules say that therapeuticCGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met.Therefore, we decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator (E0748).You asked the Plan to pre-approve this item. You say that an osteogenesis stimulator is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an osteogenesis stimulator.The Plan must follow Medicare rules. Medicare rules say that an osteogenesis stimulator is covered only if any of the indicated criteria are met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met.Specifically, the medical records indicate that the enrollee previously had a single level spinal fusion surgery, not a multilevel fusion. Additionally, an osteogenesis stimulator was not requested due to a failed spinal fusion where a minimum of nine months had elapsed since surgery or where there was a history of a previously failed spinal fusion at the same site.
Therefore, we decided that the Plan does not have to pre-approve an osteogenesis stimulator (E0748).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport and mileage provided on November 29, 2020.You asked the Plan to pay for the ambulance transport and mileage. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services are not payable as billed.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 A0425 and A0428 are not supported in the medical record. Specifically, these services were billed with an invalid modifier. For ambulance service claims, institutional-based providers and suppliers must report an origin and destination modifier for each ambulance trip provided in HCPCS/Rates. Origin and destination modifiers used for ambulance services are created by combining two alpha characters. Each alpha character, with the exception of "X", represents an origin code or a destination code. The pair of alpha codes creates one modifier. The first position alpha code equals origin; the second position alpha code equals destination. These codes were billed with modifier "HS". This means that these services were for transporting from the hospital to a scene of accident or acute event which would be incorrect. Based on this information, we decided that Medicare rules for coverage of the ambulance transport and mileage have not been met.Therefore, we decided that the Plan does not have to pay for the ambulance transport and mileage provided on November 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on October 13, 2020.You asked the Plan to pay for drug test. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported at the Place of Service (POS). We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an outpatient rehabilitation setting, therefore the POS code 11 -indicating an office setting -is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met.Therefore, we decided that the Plan does not have to pay for drug testing provided on October 13, 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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different 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 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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluid flow or fluid gf, 1 cc (Q4206).You asked the Plan to pre-approve Fluid flow or fluid gf, 1 cc (Q4206). You say that the requested Fluid flow or fluid gf, 1 cc (Q4206) is medically necessary.The Plan denied your request. The Plan says the requested Fluid flow or fluid gf, 1 cc (Q4206) is not medically necessary.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 Fluid flow or fluid gf, 1 cc (Q4206). Our reviewer says that the requested Fluid flow or fluid gf, 1 cc (Q4206) is not medically necessary. Our physician reviewer found the enrollee is with osteoarthritis in right ankle and foot. Fluid flow remains experimental for the treatment of ankle pain and degenerative joint disease. More research is needed to show safety and efficacy of fluid flow.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fluid flow or fluid gf, 1 cc (Q4206) have not been met.Therefore, we decided that the Plan does not have to pre-approve Fluid flow or fluid gf, 1 cc (Q4206).