Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a TMJ evaluation.
You asked the Plan to pre-approve the TMJ evaluation. You say that you have had jaw pain for years. You say that your jaw does not work properly and that this is causing more health problems. The Plan denied your request. The Plan says that a referral for TMJ evaluation is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 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 the TMJ evaluation. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the medical record indicates that the enrollee has suffered from pain in the TMJ area which is not severely affecting function. She has seen her primary care physician who prescribed a soft diet and heat application. When no relief occurred she was referred to her dentist. The same recommendations of a soft diet, heat/cold application, jaw exercises and stress relief were made. When the enrollee still had no relief a referral to an oral surgeon was made for a more extensive evaluation to determine if internal derangement of the joint was evident. Since no dental condition was evident for the pain, it is reasonable and necessary to perform an evaluation to determine if a structural derangement of the joint is present. Conservative measures were tried but were not successful in relieving the enrollee's pain. A TMJ evaluation would be the most prudent way to determine if an organic problem exists (arthritis or internal derangement of the joint) and a more focused treatment could be offered. 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 TMJ evaluation have been met. Therefore, we decided that the Plan has to pre-approve a TMJ evaluation.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on January 8, 2020.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says the billed services cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. 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 forthe drug testing services provided on January 8, 2020.
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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
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 that the enrollee was admitted to an acute care hospital with Covid-19 pneumonia. He was treated with Vapotherm, Remdesivir, antibiotics, and steroids. He is now on high flow oxygen. His care is supportive. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic intercept services provided on April 9, 2019.
You asked the Plan to pay for the paramedic intercept services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says procedure code S0207 is not valid for Medicare purposes.
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 S0207 is Paramedic intercept, non-hospital-based als service (non-voluntary), non-transport. We find that CPT code S0207 is not a valid code for Medicare purposes. S codes are unique temporary codes established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of paramedic intercept have not been met. Therefore, we decided that the Plan does not have to pay for paramedic intercept services provided on April 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99310) provided on August 16, 2018.
You asked the Plan to pay for nursing facility care. You say that the enrollee is unable to leave her place of
care. The Plan denied your request. The Plan says this service was not authorized.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not
have to pay for nursing facility care (99310) provided on August 16, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (G8783, 99310, G8427, G8482) provided on October 22, 2018.
You asked the Plan to pay for nursing facility care. You say that the enrollee was unable to leave her place of care. The Plan denied your request. The Plan says this was not authorized.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for nursing facility care (G8783, 99310, G8427, G8482) provided on October 22, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on January 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.
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 lab tests provided on January 21, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen 5-325mg tablets.
You asked the Plan to pre-approve Hydrocodone-Acetaminophen. You say that the medication is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.
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 Hydrocodone-Acetaminophen 5-325mg tablets.
Benefits for Hydrocodone-Acetaminophen 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Prednisone tablet and Ipratropum Bromide/Albuterol Sulfate provided on March 12, 2020.You asked the Plan to pay forthe self-administered type drugs. You say that the Plan should pay this claim.The Plan denied your request. The Plan says self-administered type drugs are not covered under your Medicare Part B benefit.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 pay forthe Prednisone tablet and Ipratropum Bromide/Albuterol Sulfate provided on March 12, 2020.Benefits for the self-administered type drugsmay be available under Medicare Part D.Contactthe 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 a portable nebulizer (E0570).
You asked the Plan to pre-approve a portable nebulizer. You say that you are requesting a portable nebulizer to use outside of the home for when you travel. The Plan denied your request. The Plan says the current nebulizer is less than 5 years old and is not in disrepair or unable to meet your medical needs. It is still within its useful lifetime and must be evaluated for repair.
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 stationary nebulizer. The stationary nebulizer serves the same purpose as the portable nebulizer. Since there is no evidence that the current nebulizer that the enrollee received was lost, stolen, or destroyed, coverage is not allowed for replacement of the nebulizer. Therefore, we decided that the Plan does not have to pre-approve a portable nebulizer (E0570).
Appeal type: Surgery
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 February 28, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.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 99190 is "Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour."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 foroxygenator assembly and operation services (CPT 99190) provided to the enrollee on February 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care and skilled nursing visits.
You asked the Plan to pre-approve home health care and skilled nursing visits. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health care and skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the medical records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care and skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health care and skilled nursing visits.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay fora preventive medicine evaluation (99397) provided on May 3, 2019.You asked the Plan to pay forthe preventive medicine evaluation. You say that you would like reconsideration because you were told this service would be covered.The Plan denied your request. The Plan says that this benefit has been exhausted.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were referred for the preventive medicine evaluation by a contract provider. The file does not show that the Plan provided notice that the preventive medicine evaluation would not be covered. Under Medicare rules, this means the preventive medicine evaluation is considered approved by the Plan.Therefore, we decided that the Plan has to pay fora preventive medicine evaluation (99397) provided on May 3, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forGeneSight psychotropic testing provided on December 19, 2019.You asked the Plan to pay forGeneSight testing. You say that this testing aligns with the Medicare coverage rules and should be approved and paid at the established rate.The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing was not ordered by a licensed psychiatrist or neuropsychiatrist.The Plan must follow Medicare rules. Medicare rules say that GeneSight assay is limited to enrollees meeting the specific clinical criteria abovewhen ordered by a licensed psychiatrist or neuropsychiatrist that is contemplating an alteration in neuropsychiatric medication. We looked at the file and Medicare rules. The documentation submitted includes a valid physician order from a licensed psychiatrist or neuropsychiatrist, who ordered this testing for purposes that are within the boundaries of Medicare's coverage for the GeneSight assay. Based on this information, we decided that Medicare rules for coverage of GeneSight testing have been met.Therefore, we decided that the Plan has to pay forGeneSight psychotropic testing provided on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on August 28, 2019.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on 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 August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on August 12, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe lab services provided on August 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on December 13, 2018.
You asked the Plan to pay for the hearing aids. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you did not have a coverage benefit for hearing aids in 2018.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on December 13, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve48 portable oxygen tanks.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says the requested tanks exceed the maximum allowed per month.The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygenin the home. We looked at the file, and Medicare rules. The rules say that no more than 1 unit of service for portable contents per month are billable. The requested tanks exceed the 1 unit of service allowed. The file also shows that the enrollee was approved for an oxygen concentrator that is greater than or equal to 48 portable tanks per month. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve48portable oxygen tanks.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on December 10, 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 if no CPT code accurately describes the procedure performed, the laboratory may report CPT code 81479 (Unlisted molecular pathology procedure) with one unit of service or may report multiple individual CPT codes describing the component test results when medically reasonable and necessary.
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 81162 is "BRCA1, BRCA2 (breast cancer 1 and 2)." 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 enrollee was diagnosed with ovarian cancer. A genetic testing panel was ordered. While BRCA genes may have been part of the testing panel, individual BRCA testing is not what was ordered or performed. Billing for the provided services with an individual and specific BRCA testing code is not supported by the documentation 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 genetic testing services provided to the enrollee on December 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveMRI of the lumbar spine for the enrollee.You asked the Planto pre-approvethe MRI. You say that this is medically necessary.The Plandenied your request. The Plansayssix weeks of physical therapy has not been completed.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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found there is no documentation of recent physical therapy. More conservative measures are needed. There are no red flags for a lumbar MRI at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met.Therefore, we decided that the Plandoes not haveto pre-approveMRI of the lumbar spine for the enrollee.