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

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the neurology visit. You say that you were being treated for three years by other providers and they have been unable to help. The Plan denied your request. The Plan says the provider is out of network and the requested treatment is available with an in-network 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 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 to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
You asked the Plan to pre-approve a MRI. You say that you need this because your home exercise program is not working. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 a MRI. Our reviewer says that the criteria for coverage of the requested MRI have not been met. Our physician reviewer found the submitted medical records do not include clear documentation indicating this is medically 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy to be provided by the out-of-network provider.

You asked the Plan to pre-approve the colonoscopy. The Plan denied your request. The Plan says you must receive your care from a network 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a colonoscopy to be provided by the out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care, per day (99233) provided from September 15, 2020, through September 17, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services are not payable as they were not prior authorized.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on September 14, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care, per day (99233) provided from September 15, 2020, through September 17, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance transportation (A0425, A0428).

You asked the Plan to pay for ambulance transportation. You say that this was medically necessary. The Plan denied your request. The Plan says that this trip was not to a covered destination.

Medicare pays for ambulance services only when they are medically reasonable and necessary. On an interim basis, Medicare will expand the list of destinations at  410.40(f) for which Medicare covers ambulance transportation to include all destinations, from any point of origin. These destinations may include, but are not limited to: any location that is an alternative site determined to be part of a hospital, CAH or SNF, community mental health centers, FQHCs, RHCs, physicians' offices, urgent care facilities, ambulatory surgery centers (ASCs), any location furnishing dialysis services outside of an ESRD facility when an ESRD facility is not available, and the beneficiary's home.

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 ambulance transportation. Our reviewer says that the criteria for coverage of ambulance services have been met. Our physician reviewer found based on the medical records provided there is documentation that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient due to her weakness, lethargy, contractures and painful decubitus ulcers. The patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The ambulance transport was medically reasonable and necessary for the patient.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transportation have been met. Therefore, we decided that the Plan has to pay for ambulance transportation (A0425, A0428).

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an injection of collagenase (a Medicare Part B prescription drug) and specialist services provided on September 30, 2020 and October 2, 2020.
You asked the Plan to waive the cost-sharing for injection and specialist visits. You say that you previously met the Plan deductible so you should only owe $300 total for these services. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for injection and $25 copayment for each specialist visit. The allowed amount of the injection is $3,403.03, resulting in a coinsurance amount of $680.61. There were 2 visits for specialist services, resulting in a total copayment amount of $50. Your total cost-sharing obligation is therefore $730.61. You have been asked to pay 20% coinsurance for injection and $25 copayment for each specialist visit. Injection and specialist visits fall within the "Medicare Part B Prescription Drugs" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-sharing for an injection of collagenase (a Medicare Part B prescription drug) and specialist services provided on September 30, 2020 and October 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiac catheterization procedures provided on November 19, 2020.
You asked the Plan to waive the copayment for outpatient surgery. You say that you did not stay overnight so should not have to pay this copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $275 copayment for outpatient surgery provided in an outpatient hospital facility. You have been asked to pay $275 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for cardiac catheterization procedures provided on November 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed tomography (CT), heart, without contrast material, with quantitative evaluation of coronary calcium (75571).
You asked the Plan to pre-approve the CT scan. You say that you feel that this service is medically necessary and should be covered by the plan. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed tomography (CT), heart, without contrast material, with quantitative evaluation of coronary calcium (75571).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (K0861) and related accessories.
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options and related accessories. You say that the enrollee has a need for a custom seating system and a wheelchair that accommodates the enrollee's unique body shape and addresses the enrollee's medical conditions. The Plan denied your request. The Plan says rules for pre-approval have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a Group 3 power wheelchair with multiple power options is being requested for use in a SNF or hospital. Medicare does not cover durable medical equipment for use in this setting. Furthermore, accessories related to a Group 3 power wheelchair are not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (K0861) and related accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and dizziness and was treated for acute GI bleed, anemia and hypotensive shock. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies (A4520, A4554).
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs incontinence supplies to keep cleaner and prevent skin breakdown. The Plan denied your request. The Plan says rules for pre-approval have not been met.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (A4520, A4554).
Your complaint about receiving erroneous or ambiguous information regarding the enrollee's benefit from a representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services rendered on January 10, 2020 to February 10, 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 codes 11042 and 11045 are 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 11042 is debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less. The definition of code 11045 is debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure). We find that CPT codes 11042 and 11045 are not supported in the medical record. Specifically, there is no documentation of debridement of 20 sq cm subcutaneous tissue on January 15, 2020 to support code 11042. There is no documentation of debridement of an additional 20 sq cm of subcutaneous tissue on January 10, 2020; February 7, 2020; and February 10, 2020 to support code 11045. 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 debridement services rendered on January 10, 2020 to February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-therapeutic CGM and accessories (A9276, A9277, A9278, 95250).
You asked the Plan to pre-approve a non-therapeutic CGM and accessories. You say that a continuous glucose monitor would offer more control on behalf of the enrollee and provider to control blood sugar and diabetic complications. The Plan denied your request. The Plan says coverage criteria 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 requested items describe components and accessories of a non-therapeutic CGM. Medicare does not provide coverage for non-therapeutic CGMs. Therefore, we decided that the Plan does not have to pre-approve a non-therapeutic CGM and accessories (A9276, A9277, A9278, 95250).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 95908, CPT 95885) provided to the enrollee on March 23, 2020.
You asked the Plan to pay for the services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support services 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 the denied codes is: CPT 95908: Nerve conduction studies; 3-4 studies CPT 95885: Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure) 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 the medical records provided indicate pedicle screw stimulation was performed which are not baseline nerve conduction studies which would include measurements of amplitude, latency, and conduction velocity, therefore, not meeting the criteria for CPT codes 95909 and 95885. 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 the services (CPT 95908, CPT 95885) provided to the enrollee on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625).

You asked the Plan to pre-approve the radiofrequency ablation. You say that you are experiencing lower back pain and you are appealing the denial. The Plan denied your request. The Plan says this procedure is considered not medically necessary and investigational as this treatment has not been proven as effective as standard treatment of sacroiliac joint pain.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a colonoscopy and endoscopy at an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit and there are network providers who can provide similar services.
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 a referral for a colonoscopy and endoscopy at an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided on August 13, 2020, to September 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for pain management services. You say that the physician left the practice and this provider took over those patients. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these services.
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 pain management services provided on August 13, 2020, to September 11, 2020 by an out of network (OON) provider.