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

We decided that the Plan does not have to pay for the BLS non-emergency ambulance service to be provided by the out of network provider on July 6, 2019.
You asked the Plan to pay for the ambulance services. You say that please review the documents and records for medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 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 pay for these items/services. Therefore, we decided that the Plan does not have to pay for the BLS non-emergency ambulance service to be provided by the out of network provider on July 6, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a complete maxillary denture (code D5110) and a complete mandibular denture (code D5120).
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. The Plan denied your request. The Plan says that you were asked for needed x-rays, but they were not provided. The Plan also says that there is no medical need for these services.
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. The Plan covers the complete maxillary and mandibular dentures. when the services are medically necessary and reasonable. 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 complete maxillary and mandibular dentures. Our reviewer says that you need these dental items. Our physician reviewer found the enrollee appears to be edentulous. Our reviewer also found that complete maxillary and mandibular dentures are reasonable and necessary for masticatory function. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the complete maxillary and mandibular dentures. have been met. Therefore, we decided that the Plan has to pre-approve a complete maxillary denture (code D5110) and a complete mandibular denture (code D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for otolaryngology services provided to the enrollee on May 2, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 69220 remains 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 69220 is "Debridement, mastoidectomy cavity, simple (e.g., routine cleaning)." 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 coded correctly. Our coding reviewer found CPT code 69220 is not supported by the medical record. The documentation does not mention a mastoidectomy cavity. There is no evidence that a debridement was performed during this episode of care. 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 otolaryngology services provided to the enrollee on May 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel
You asked the Plan to pre-approve Enbrel. You say that the enrollee's disease has remained stable on this medication. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Enbrel
Benefits for Enbrel may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro upper extremity assist device
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that this device is helpful for treatment of the enrollee's condition.
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 the device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no indication that this device will serve to significantly enhance long-term health and/or functional outcomes. There is an apparent lack of peer-reviewed, randomized controlled trials supporting this device in those with spastic hemiparesis. It appears this device is a convenience item, and as such is not 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro upper extremity assist device
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chemotherapy drugs to be provided by the facility.
You asked the Plan to pre-approve self-administered drugs. You say that you obtain the medications from the pharmacy and administer them in the physician's office; therefore, this does meet coverage criteria. The Plan denied your request. The Plan says the denial of authorization for these drugs is correct, because the pharmacy will not be directly supplying the medications to the provider and therefore these medications are not eligible for coverage under Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. If these drugs were purchased by the physician's office and billed by the office along with administration, then the medications would be eligible for Medicare Part B coverage. Therefore, we decided that the Plan does not have to pre-approve chemotherapy drugs to be provided by the facility.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinitial inpatient consultation services provided May 3, 2019.You asked the Plan to pay forinitial inpatient consultation. You say that other specialties have been called in and billed by providers.The Plan denied your request. The Plan says the provider should consider a more appropriate code for consultation codes.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will bedenied.In this case, the the provider should consider a more appropriate code for consultation codes.. Based on this information, we decided that Medicare rules for coverage of initial inpatient consultation have not been met.Therefore, we decided that the Plan does not have to pay forinitial inpatient consultation services provided May 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upgraded electronics.
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that you need the power wheelchair, accessories, and upgraded electronics. The Plan denied your request. The Plan says there is no need to control the approved power options through the joystick.
The Plan follows Medicare rules. Documentation shows that you have normal range of motion and 5/5 strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for the you to be able to control the power options using their own switches which are included in the allowance of these power options. This means that Medicare rules for coverage of the upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve the Group 3 power wheelchair upgraded electronics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider
You asked the Plan to pre-approve an out-of-network second opinion. You say that you would prefer to see because your family has used this provider in the past, with good results. The Plan denied your request. The Plan says there are in-network orthopedic surgeons who can provide a second opinion.
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 medical services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 8, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not contain documentation to support the coding criteria for code billed on date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the definition of HCPCS code G0482 is "Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed." 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the provided medical records do not support the coding of HCPCS G0482. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services (99203, 97022, 11055, and 11721) provided on February 13, 2019
You asked the Plan to pay for podiatry services. You say that you were not aware prior authorization was required. The Plan denied your request. The Plan says services from out-of-network providers require authorization.
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 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 pay for these items/services. Therefore, we decided that the Plan does not have to pay for podiatry services (99203, 97022, 11055, and 11721) provided on February 13, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 1 additional urinary drainage bag (A4358) per month.
You asked the Plan to pre-approve urinary drainage bag. You say that 2 bags do not last an entire month. You should be able to get one additional bag. You cannot wash out the bags or hang them to dry. Not being able to change the bags makes being in public uncomfortable. The Plan denied your request. The Plan says this request exceeds the Medicare limit of 2. The provider also said there is no medical reason why you need 3 urine bags.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare allows 2 bags per month. This request exceeds the allowed Medicare amount. Based on this information, we decided that Medicare rules for coverage of urinary drainage bag have not been met. Therefore, we decided that the Plan does not have to pre-approve 1 additional urinary drainage bag (A4358) per month.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 available records, the enrollee does not meet criteria for coverage of IRF.
The enrollee is currently medically stable and there is no evidence of complex medical issues that require
monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While she
may benefit from continuing physical therapy (PT) and occupational therapy (OT), there is no evidence of need
for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an
interdisciplinary approach to rehabilitation 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee requires physical and occupational therapy. The Plan denied your request. The Plan says the enrollee's needs are for custodial care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, the enrollee has stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at maximal assist with functional mobility. He requires varying assist with activities of daily living. There are no identifiable skilled therapy services. The enrollee does not require skilled services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitoring system.
You asked the Plan to pre-approve a continuous glucose monitor. You say that it is hard and painful to finger stick test and you would like a CGM to maintain healthy sugar levels. The Plan denied your request. The Plan says you do not check glucose levels more than 4 times a day and are not insulin treated.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file, and Medicare rules. The record shows you are not insulin treated. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) provided to the enrollee on July 22, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was not billed correctly.
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 code 99190 is not supported in the medical record. Specifically, payment for this code is included in the payment to the facility. 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 oxygenator assembly and operation services (CPT 99190) provided to the enrollee on July 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve frames purchase (V2020) tint photochromatic, per lens (V2744).
You asked the Plan to pre-approve the vision services. You say that through the provider you got 3 pairs of eyeglasses with the exact same specifications that the other provider had and you saved $200. The Plan denied your request. The Plan says non-emergent services with out of network providers require prior-authorization prior to services being rendered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when a year and up to $800 per year to be used toward the purchase of
eyeglasses (frames and lenses) or contact lenses. You must get an authorization when using out of network providers. We looked at the file and the Plan's rules. The provider is non-contracted and there was no pre-authorization. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pre-approve frames purchase (V2020) tint photochromatic, per lens (V2744)
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 the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found based on
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
upper extremity ischemia and a pleural effusion in the setting of known lung cancer. The enrollee underwent an
upper extremity amputation and drainage of her effusion. The enrollee is not intubated/ventilated. As LTACHs
and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to
the LTACH. The enrollee can remain at the current ACH until such time 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.