Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 multiple power options wheelchair with combination power tilt and recline, power elevating leg rests, and upgraded electronics for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a group 2 single power wheelchair with power tilt and elevating leg rests will meet needs for positioning and mobility.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the requested K0843 group 2 multiple power wheelchair with free upgrade to K0862 group 3 multiple power wheelchair with combination power tilt and recline, power elevating leg rests and associated electronics is not medically necessary. The mobility deficit is not due to a neurological condition, myopathy, or congenital deformity. The enrollee has sufficient upper extremity strength and function that they do not need the multiple power options (E2377, E2311, E2313). The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control.The documentation does not reveal evidence of spasticity, intermittent catheterization for bladder management, or clear inability to perform a functional weight shift. The appointment notes the enrollee was able to stand up from the wheelchair and return to chair.

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 pre-approve a group 3 multiple power options wheelchair with combination power tilt and recline, power elevating leg rests, and upgraded electronics for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital physician visit.

You asked the Plan to pay for physician visit. You say that you did not receive proper notice of the enrollee's benefit determination, hence the untimely submission of the claim. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not submitted within the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for physician visit was not filed. 

This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a hospital physician visit.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraocular lens (IOL) upgrade.

You asked the Plan to pay for the IOL upgrade. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this is not a covered service.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The service you received is not covered according to your Plan's routine vision and eyewear benefit. In addition, the contracted provider with the Plan made you sign an acknowledgement that this service would not be covered by Medicare. Based on this information, we decided that the Plan's rules for coverage of the IOL upgrade have not been met. Therefore, we decided that the Plan does not have to pay for the intraocular lens (IOL) upgrade.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the gingival irrigation (D4921 x 4), scaling in
presence of generalized moderate or severe gingival inflammation (D4346), and the drugs or medicaments
(D9630).

You asked the Plan to reimburse you for the dental services. You say that you were told that you needed
gingival irrigation. You also say that you were told that the services would be covered. The Plan denied your
request. The Plan says gingival irrigation is not listed as a covered service. The Plan says that scaling in
presence of generalized moderate or severe gingival inflammation is not listed as a covered service. The Plan
also says that drugs or medicaments is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for
the gingival irrigation (D4921 x 4), scaling in presence of generalized moderate or severe gingival
inflammation (D4346), and the drugs or medicaments (D9630).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute
setting.

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. The shortterm
acute care hospital can provide for all of the patient's present inpatient care needs and the patient is
receiving an appropriate level of care in the present setting. Continued care in the short-term acute care hospital
is appropriate until the patient is stable to transfer to a lower level of care. Our physician reviewer found that
the enrollee's condition does not meet Medicare criteria for LTACH services.

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 LTACH services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning (99497) and critical care services (99291).

You asked the Plan to pay for the advance care planning and critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.

The CPT Code Manual definition of CPT code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

We asked our coder 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 advance care planning and critical care services. Our reviewer says that CPT code 99497 does not meet criteria for billing or reimbursement consideration. The medical record provided do not include sufficient documentation to validate an advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate was performed, herefore, this service cannot be verified. Our coder found CPT code 99291 does not meet criteria for billing or reimbursement consideration. The medical documentation submitted does not include total time spent providing critical care services therefore, this service cannot be verified.

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 advance care planning and critical care services have not been met. Therefore, we decided that the Plan does not have to pay for advance care planning (99497) and critical care services (99291).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI).

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 code 72148 is 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 72148 is magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material.

We find that CPT code 72148 is not supported in the medical record. Specifically, there is no documentation of an interpretation report of a lumbar spine MRI. 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 magnetic resonance imaging (MRI).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray.

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 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 test at issue in this appeal, a chest x-ray, was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
chest x-ray.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pantoprazole for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Pantoprazole for the enrollee.

Benefits for this drug 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for biomarker testing.

You asked the Plan to pay for the biomarker testing. You say that you would like reconsideration because this
testing provides insight into the member's pain and medication compliance. The Plan denied your request. The
Plan says specimen validity tests are not covered.

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 pay for the biomarker testing. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there was no diagnostic indication for these tests based on the provided documentation. Basic
urine drug screening was warranted but these other functional tests were not justified and would not directly
lead to improved outcome.

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 biomarker testing have not been met. Therefore, we decided that the Plan
does not have to pay for biomarker testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown repair necessitated by restorative material failure (D2980).

You asked the Plan to pay for the crown repair. You say that this service was necessary to save your crown. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown repair necessitated by restorative material failure (D2980).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99285).

You asked the Plan to pay for the emergency visit. You say that the enrollee came to ED with abdominal pain. Multiple labs, EKG and x-ray was performed. Was treated with IV medication and IM parental medication and admitted. Medical record attached for review. The Plan denied your request. The Plan says 99284 more accurately describes the services rendered, therefore the claim paid for code 99284.

The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided.

In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status):

1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity.

In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function.

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 emergency visit Our reviewer says that the Medicare criteria for coverage was not met. Our reviewer found the medical records provided do not include sufficient documentation to meet criteria to meet the description of CPT code 99285, therefore it is inappropriate to submit CPT code 99285 for services.

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 emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor 
 
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that you are tired of poking 
your fingers 4-5 times a day. The Plan denied your request. The Plan says the medical records show you are not 
on insulin and only test once a day. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose 
testing at least four times per day or use insulin with at least three daily injections. Based on this information, 
we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram.

You asked the Plan to waive the copayment for the electrocardiogram. You say that you never had a copayment for this test before. The Plan denied your request. The Plan says you were charged this copayment correctly.

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 a $10 copayment for Outpatient Diagnostic Tests.

You have been asked to pay a $10 copayment for the electrocardiogram. the electrocardiogram falls within the Outpatient Diagnostic Tests 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 the electrocardiogram.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six additional physical therapy visits for the enrollee.

You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee will now have 30 approved physical therapy visits.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition and the documentation does not indicate that the functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has been instructed in a home exercise program and the one additional authorized therapy session can reinforce this program. The requested services are not part of a maintenance program,and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further 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 the additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six additional physical therapy visits for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance the air ambulance transport.

You asked the Plan to waive the coinsurance the air ambulance transport. The Plan denied your request. The
Plan says that the claim was processed according to your benefit.

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 a 20%
coinsurance for each fixed wing, rotary, or water ambulance transport.

You have been asked to pay a 20% coinsurance for the air ambulance transport. The air ambulance transport
falls within the each fixed wing, rotary, or water ambulance transport 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 coinsurance the air ambulance transport.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for TAVR (33361).

You asked the Plan to pay for the TAVR. You say that you would like reconsideration because this service was medically necessary. The Plan denied your request. The Plan says this service was not reported correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that claim lines billed without modifier -Q0 shall be returned as unprocessable.

We find that CPT code 33361 is not supported in the record. Specifically, this service was not billed with the required Q0 modifier. Based on this information, we decided that Medicare rules for coverage of the TAVR have not been met. Therefore, we decided that the Plan does not have to pay for TAVR (33361).