Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically appropriate. The Plan denied your request. The Plan says the enrollee's current needs are being met in the current acute setting. The plan says that ongoing skilled needs could be provided at a lower level, such as a vent capable SNF.
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 the enrollee is currently undergoing treatment at an acute care hospital (ACH). At baseline, the enrollee has a tracheotomy and uses NiPPV at night. The enrollee is currently tolerating a tracheotomy collar during the daytime and ventilator support at night. There appears to be no expectation that the enrollee will be decannulated or liberated from nightly ventilator use. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa injections for the enrollee.You asked the Plan to pre-approveEuflexxa. You say that this is medically necessary.The Plan denied your request. The Plan says that they did not receive documentation or medical records supporting the medical necessity for a step therapy exception.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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary for the enrollee in this case.The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet criteria for Euflexxa.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approveEuflexxa injections for the enrollee
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve air ambulance transport from California to New Jersey for the enrollee.You asked the Plan to pre-approvethe transport. You say that you need this transport to get the enrollee home.The Plan denied your request. The Plan says the member does not meet criteria for air ambulance transfer.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. The patient must be transported to the nearest hospital with appropriate facilities.The request to take the trip from California to New Jersey is based on personal preference and convenience only. Based on this information, we decided that Medicare rules for coverage of the transport have not been met.Therefore, we decided that the Plan does not have to pre-approveair ambulance transport from California to New Jersey for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forthe mammogram provided on April 28, 2019.You asked the Plan to pay forthe mammogram. The Plan denied your request. The Plansays that this was 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 pay for the mammogram. Our reviewer says that the requested mammogram is considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 66-year-old female with family history of ovarian cancer. A baseline screening mammogram at age 66 complies with all medically necessary guidelines.We looked at thisphysician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the mammogram have been met.Therefore, we decided that the Plan has to pay forthe mammogram provided on April 28,2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second rolling walker.You asked the Plan to pre-approve a rolling walker. You say that you need another rolling walker for outside home use only.The Plan denied your request. The Plan says you received a new rolling walker in August 2019 and duplicate equipment is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a rolling walker. Yourrolling walker serves the same purpose as an outdoorrolling walker.The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use only outside the home. Therefore, we decided that the Plan does not have to pre-approvea second rolling walker.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services coded 99239 provided on June 7, 2019.
You asked the Plan to pay for the hospital discharge day management services. 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. 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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed. A documented duration of 31 minutes or more is required to support this code. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services coded 99239 provided on June 7, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forphysical therapy (PT) (97039) provided on July 22, 2019 to August 2, 2019 by out of network provider.You asked the Plan to reimburse you forPT. You say that you saw an advertisement on the television about therapies with laser and you thought this could help with your pain. You say that when you arrived at the office you wereasked about your Planand you were charged $1,000. You also say that you were told bythat office that the plan would make a reimbursement for the therapy.The Plan denied your request. The Plan says you must receive your care from a network provider. The Plan says that in most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. The Plan further says if you need medical care that Medicare requires the Plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. The Plan says you will need to obtain authorization from the plan prior to seeking care.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 be reimbursed 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 has network providers available who can provide 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 be reimbursed for these items/services.Therefore, we decided that the Plan does not have to reimburse you forphysical therapy (PT) (97039) provided on July 22, 2019 to August 2, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 25, 2019, and July 26, 2019.You asked the Plan to pay forthe services. You say that the enrollee was not in hospice.The Plan denied your request. The Plan says upon discharge or revocation, fee-for-service Medicare continues to cover the beneficiary through the end of the month when the beneficiary revokes or is discharged from hospice alive.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 July 2, 2019. 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 services provided on July 25, 2019, and July 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory testing coded 80156, 80157, 80177, 80201, 80162, 80159, and 80173 provided on March 25, 2019.You asked the Plan to pay forthe laboratory testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plansays the services billed are not separately payable.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 80156, 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, the documentation includes definitive drug class testing for which G0480 has already been reimbursed. These codes represent testing for therapeutic drug levels. There is no laboratory report showing separate line item results for the additional therapeutic drug levels billed. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory testing coded 80156, 80157, 80177, 80201, 80162, 80159, and 80173 provided on March 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe Sequal Eclipse 5 portable oxygen concentrator and battery pack provided on July 10, 2019 by out of network provider.You asked the Plan to reimburse you forthe portable oxygen concentrator and battery pack. You say that the Plan told you that a portion of the purchase price was covered.The Plan denied your request. The Plan says Medicare guidelines say purchased oxygen equipment is statutorily non-covered.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 reimburse you 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. Purchased oxygen equipment is statutorily non-covered by Medicare.We found no exception that would require the Plan to reimburse you for these items/services.Therefore, we decided that the Plan does not have to reimburse you forthe Sequal Eclipse 5 portable oxygen concentrator and battery pack provided on July 10,2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewings provided on September 10, 2019.You asked the Plan to pay forthe bitewings. You say that there should be no denials for you because you are paying a yearly premium for routine dentalwork. You also say that these x-rays were necessary to detect cavities and are the most accurate x-rays available for that particular tooth.The Plan denied your request. The Plan says the service exceeds the frequency limitation in your benefit 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, bitewings are limited to one set per plan year. The record shows that you received bitewing x-rays on March 7, 2019 and your bitewings benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe bitewings provided on September 10, 2019.Your complaint about being disgusted with the Plan's denial 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the flow cytometry services coded 88189 provided on August 8, 2019.You asked the Plan to pay forthe flow cytometry services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not separately payable.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 88189 is flow cytometry, interpretation; 16 or more markers.We find that CPT code 88189 is not supported in the medical record. Specifically, the enrollee was inpatient for these services. Payment cannot be made to any provider or supplier other than the facility or hospital for services furnished to the enrollee while an inpatient. The facility or hospital must furnish all necessary covered services to the enrollee either directly or under arrangements made between the facility and hospital and outside providers. The enrollee received these servicesin the facility during and/orafter surgery. Payment for this service would have been included under the facility claim. Based on this information, we decided that Medicare rules for coverage of the flow cytometry services have not been met.Therefore, we decided that the Plan does not have to pay forthe flow cytometry services coded 88189 provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to "the beneficiary" by "the provider" on August 27, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 95940 and 95937 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 95940 is continuous intraoperative neurophysiology monitoring in theoperating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure). The definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), eachnerve, any 1 method.We find that CPT codes 95940 and 95937 are not supported in the medical record. Specifically, the operative report did not contain documentation that continuous intraoperative neurophysiology monitoring was performed to support code 95940. Code 95937-26 is not supported because it involves inappropriate use of the -26 modifier. 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 forthe services rendered to "the beneficiary" by "the provider" on August 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean exception to the 50 mile limit for routine transportation.You asked the Plan to pre-approveexceptions to supplemental benefits. The Plan denied your request. The Plan says that this request is not covered by the plan.Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits.Therefore, we decided that the Plan does not have to pre-approvean exception to the 50 mile limit for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.You asked the Plan to pre-approvea portable oxygen concentrator. You say that it is difficult for your spouse to take you to appointments with your portable tanks.The Plan denied your request. The Plan says your current home oxygen with portable tanks serves your in home needs.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. Medicare will not pay forequipment used for a patient's comfort or for the convenience of a person caring for the patient.The record shows that you have a stationary oxygen system with refillable portable tanks. This stationary oxygen system with refillable portable tanks meets your in-home needs and serves the same purpose as a portable oxygen concentrator.Therefore, we decided that the Plan does not have to pre-approvea portable oxygen concentrator
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high strength lightweight wheelchair and accessories.You asked the Plan to pre-approve a high strength lightweight wheelchair and accessories. You say that the enrolleecannot walk andneeds a high strength lightweight wheelchair and accessories for ADLs.The Plan denied your request. The Plan says the enrollee's doctor did not send any medical records to review.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.The records provided do not support the criteria.Based on this information, we decided that Medicare rules for coverage of a high strength lightweight wheelchair and accessories have not been met.Therefore, we decided that the Plan does not have to pre-approvea high strength lightweight wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit for physician's services and drug testing to be provided by "the provider". You asked the Plan to pre-approve the office visit for physician's services and drug testing. You say that this provider has been treating you for several years for an opioid addiction and you feel comfortable remaining under the care of this provider. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider inthis 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 an office visit for physician's services and drug testing to be provided by "the provider".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper and lower leg functional electrical stimulator
(E0770) to be provided by the out of network provider.
You asked the Plan to pre-approve the functional electrical stimulator. You say that you purchased this
equipment in 2009 and have first-hand experience improvement of your gait so you request reconsideration to
provide the financial support you need to obtain the new equipment. The Plan denied your request. The Plan
says enrollee's must receive their medical services from an in-network provider. The plan says if an enrollee
requires medical care that Medicare requires the plan to cover and there are no in-network providers who can
provide the care then the enrollee can receive the care from an out-of-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 pre-approved care.
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 upper and lower leg functional electrical stimulator (E0770) to be provided by the out of network provider.