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

We decided that the Plan does not have to pre-approve 120 additional routine transportation trips.
You asked the Plan to pre-approve 120 additional routine transportation trips. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. You have currently used 4 one-way transportation trips. Based on this information, we decided that you once you use your additional plan covered 20 one-way transportation trips, you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 120 additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring system.
You asked the Plan to pre-approve a continuous glucose monitor. You say that a CGM will help you to have a better control of the diabetes. The Plan denied your request. The Plan says criteria are not met.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cialis for the enrollee.
You asked the Plan to pre-approve Cialis. 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 Cialis for the enrollee.
Benefits for Cialis 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 BRCA1 and BRCA2 screening testing.
You asked the Plan to pay for screening tests. You say that you are concerned with the high mortality rate among direct family members and want to be tested to prevent it from suddenly happening. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because these tests are not covered for screening purposes.
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 tests at issue in this appeal, screening tests, are being requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for BRCA1 and BRCA2 screening testing.
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 services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital 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. Our physician reviewer found based on the provided medical records you are receiving necessary services and are at an appropriate level of care in the acute care hospital. Continued care at this level is appropriate until you are stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 63055-AS billed for date of service July 16, 2019.
You asked the Plan to pay for CPT code 63055-AS. You say that the medical records provided support the service in dispute. The Plan denied your request. The Plan says CPT code 63055-AS is not supported by the medical records submitted.
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 63055-AS is transpedicular approach with decompression of spinal cord. We find that CPT code 63055-AS is not supported in the medical record. Specifically, the op note does not describe a transpedicular approach and transpedicular decompression procedure as being performed on the date of service in dispute. Based on this information, we decided that Medicare rules for coverage of CPT code 63055-AS have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 63055-AS billed for date of service July 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea grab bar for the enrollee.You asked the Plan to pre-approvea grab bar. You say that the enrollee is at risk for falls.The Plan denied your request. The Plan says that this is not covered by Medicare.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea grab bar for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that you thought the enrollee needed medical attention and so you called 911. You say that the enrollee was not responding and her breathing was not normal. You stated that the enrollee has had similar symptoms in the past which have resulted in either pneumonia or a blood clot. After the responders had arrived and were examining the enrollee, you say the enrollee awoke. You say the enrollee did not want to go to the hospital and declined transportation.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 3, 2019.The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the abdomen and pelvis (74177) and CT scan of the chest (71250).You asked the Plan to pre-approvea CT scan of the abdomen and pelvis and CT scan of the chest. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan of the abdomen and pelvis and CT scan of the chest. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 2020 NCCN guidelines indicate that yearly CT of the chest, abdomen and pelvis is not indicated unless there are clinical concerns of metastatic disease. This enrollee's physical exam has been normal and his most recent carcinoembryonic antigen (CEA) level is 2.4 which is well within the normal range. The clinical notes describe no laboratory or clinical findings to suggest metastatic disease and apparently conventional imaging on a yearly basis has revealed no evidence of tumor. The enrollee has a pending colonoscopy. At this point in time the medical necessity of CT of the chest, abdomen and pelvis has not been established.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the abdomen and pelvis and CT scan of the chest have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the abdomen and pelvis (74177) and CT scan of the chest (71250).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network radiation oncologist.
You asked the Plan to pre-approve these services. You say that you were approved for a biopsy.
The Plan denied your request. The Plan says the services are available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan approved a referral for a surgery consult and a biopsy was taken, and the surgeon is not planning to proceed with surgery.
You have not been seen by a radiation oncologist at this facility. We found no exception that would require the
Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a
referral to an out-of-network radiation oncologist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on August 26, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory 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 a covered benefit.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 forthe laboratory services provided on August 26, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically necessary.The Plan denied your request. The Plan says rules for coverage are not met.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing (CPT 95937) provided on December 27, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not covered.
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 95937 is "Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method". We find that CPT code 95937 is not supported in the medical record. Specifically, CPT 95937 does not represent train of four testing. There is a more appropriate CPT code for train of four testing. Based on this information, we decided that Medicare rules for coverage of CPT 95937 have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing (CPT 95937) provided on December 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted neurological or neuromuscular procedure (95999).
You asked the Plan to pay for unlisted neurological or neuromuscular procedure. You say that the records provided should support the service in dispute. The Plan denied your request. The Plan says it is inappropriate to bill the code for Unlisted neurological or neuromuscular diagnostic procedure for Train of Four Monitoring.
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 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 unlisted neurological or neuromuscular procedure. Our reviewer says that the billing of CPT 95999 is not supported. Our physician reviewer found the enrollee received intraoperative neurophysiology monitoring. All of the procedures (SSEP, EMG, EEG, overall monitoring) except train of four monitoring (TO4) have their own billing codes. TO4 monitoring is considered part of the overall monitoring code and does not have its own separately billable code. There is no evidence that any other unlisted neurologic/neuromuscular procedure was performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of unlisted neurological or neuromuscular procedure have not been met. Therefore, we decided that the Plan does not have to pay for unlisted neurological or neuromuscular procedure (95999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray(D0220), resin-based composite (D2391), periodic oral evaluation (D0120), and prophylaxis (D1110) provided on June 20, 2019 and November 26, 2019.You asked the Plan to pay forthe first intraoral periapical x-ray, resin-based composite, periodic oral evaluation, and prophylaxis. You say that you were denied benefits that you had enrolled in with your plan for 2019.The Plan denied your request. The Plan says the first intraoral periapical x-ray and resin-based composite are not listed as covered benefits. The Plan also says that you exceeded your benefit limitations for the periodic oral evaluation and prophylaxis.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, first intraoral periapical x-ray and resin-based composite are not among those covered under this benefit. The contract clearly states that you are limited to 1 oral exam(s) and 1 cleaning(s) every year. The record shows that you received a periodic oral evaluation and prophylaxis on May 14, 2019 and your oral exam and cleaning benefits were then exhausted. The records also show that you were not enrolled in any optional supplemental package for the 2019 benefit period.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray (D0220), resin-based composite (D2391), periodic oral evaluation (D0120), and prophylaxis (D1110) provided on June 20, 2019 and November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for foot orthotics purchased on August 8, 2019 and September 18, 2019.
You asked the Plan to reimburse you for foot orthotics. You say that your orthopedic doctor prescribed the orthotics and this is the only supplier to carry them. The Plan denied your request. The Plan says these items are not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records do not show that you suffer from diabetic foot disease or you wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to reimburse you for foot orthotics purchased on August 8, 2019 and September 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CYP panel rendered to enrollee on October 8, 2019.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 the services are not covered.The Plan must follow Medicare rules. The rules say that all CYP panels should be billed with 81479 and are non-covered.The testing at issue is a CYP panel. The file shows that the testing was not billed with the required 81479 code. Furthermore, this testing is not covered by Medicare.Therefore, we decided that the Plan does not have to pay for the CYP panel rendered to enrollee on October 8, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 Physical Therapy visits. You asked the Plan to pre-approve the Physical Therapy visits. You say that you were released from the hospital and need home health services for follow-up care. The Plan denied your request. The Plan says coverage criteria have not been met because you are not homebound. 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 the Physical Therapy visits. Our reviewer says that the records do not indicate that you are homebound and that leaving the home is a significant and taxing effort. Our physician reviewer found the records do not show an objective physical exam with a detailed physician gait and neuromuscular evaluation that reveals functional deficits that require skilled therapy services to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. It is unclear how much prior therapy you have had and the outcome of this therapy. 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 Physical Therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 Physical Therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on September 18, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on September 18, 2019.