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

We decided that the Plan does not have to pre-approve an exception to the 50-mile limit for routine transportation.
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you need transportation to get to doctor appointments. The Plan denied your request. The Plan says that your request exceeds the benefit limit.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to pre-approve an exception to the 50-mile limit for routine transportation.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for automatic blood pressure monitor (A4670) provided
November 13, 2019.
You asked the Plan to pay for automatic blood pressure monitor. You say that you are appealing the denial for
a duplicate claim because this was only submitted once. The Plan denied your request. The Plan says payment
for this item is included in the transportation fee.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules. Medicare does not allow for separate billing of these services and supplies.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of automatic blood pressure monitor have not been met. Therefore, we decided that the Plan does not
have to pay for automatic blood pressure monitor (A4670) provided November 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (95816) provided on May 21, 2019.You asked the Plan to pay for the electroencephalogram. 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 95816 is electroencephalogram (EEG); including recording awake and drowsy.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 electroencephalogram. Our reviewer says that CPT code 95816 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include the interpretation and report to validate that an Electroencephalogram (EEG); including recording awake and drowsy was performed. 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 electroencephalogram havenot been met. Therefore, we decided that the Plan does not have to pay for an electroencephalogram (95816) provided on May 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing evaluation and admission.
You asked the Plan to pre-approve the skilled nursing evaluation and admission. You say that the enrollee needs to stay in a SNF to help care for his daily needs. The Plan denied your request. The Plan says these services are not reasonable and necessary.
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 the skilled nursing evaluation and admission. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the skilled nursing evaluation and admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing evaluation and admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid battery provided to the enrollee on October
22, 2019.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that Medicare does
not pay for this service.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related
services.
Though these services 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 aid battery
provided to the enrollee on October 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forsupply allowance for therapeutic continuous glucose monitor (K0553) provided September 8, 2019.You asked the Plan to pay forsupply allowance for therapeutic continuous glucose monitor. You say that please review the attached records again, they do support medical necessity per Medicare guidelines.The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met.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 non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay forsupply allowance for therapeutic continuous glucose monitor (K0553) provided September 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the plan has additional network specialists, as well as network tertiary level facilities available that can provide the requested services.
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. 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 provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve urinary catheters (E1399).
You asked the Plan to pre-approve Speedicath brand urinary catheters. You say that the original catheters
allowed you to catheter without pain and bleeding. The new catheters are flimsy, hard to insert, are not
lubricated and cause bleeding and urinary track infections. The Plan denied your request. The Plan says the
requested item is considered an upgrade and not medically necessary. The plan has instead approved Cure
Catheters brand
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 urinary catheters. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found an equivalent type catheter that is covered by
your plan. The brand catheters are 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 urinary catheters have not been met. Therefore, we decided
that the Plan does not have to pre-approveurinary catheters (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (L1833) and suspension sleeve (L2397) provided November 8, 2019.You asked the Plan to pay forthe orthoses. You say that you are a non-participating provider and are making every effort to provide the supporting documentation needed.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.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 forknee orthosis (L1833) and suspension sleeve (L2397) provided November 8, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care
You asked the Plan to pay for the acute inpatient hospital care. You say that the acute inpatient hospital care
provided was medically necessary. The Plan denied your request. The Plan says that the acute inpatient hospital
care provided was not medically necessary.
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 pay for the acute inpatient hospital care. Our
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our
physician reviewer found the review indicates that the enrollee presented to the Emergency Department (ED)
on July 26, 2019 with complaints of right knee pain subsequent to a fall. She was admitted with a diagnosis of a
right tibial plateau fracture. An MRI was completed and showed non-displaced subchondral fracture in lateral
femoral condyle, chronic tear in lateral meniscus, large joint effusion. There were no acute surgical
recommendations. The enrollee was recommended to be toe touch weight bearing on the right leg for six weeks
and was discharged to a skilled nursing facility with Tylenol for pain management. The review has determined
that the record showed 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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for low osmolarcontrast material (Q9967) provided on October 4, 2019.You asked the Plan to pay for the low osmolar contrast material. 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 Q9967 is low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml .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 low osmolar contrast material. Our reviewer says that CPT code Q9967 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted do not include documentation of the administration of Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml on October 4, 2019. 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 low osmolar contrast material have not been met. Therefore, we decided that the Plan does not have to pay for low osmolar contrast material (Q9967) provided on October 4, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the additional chemotherapy administration (96417). We decided that the Plan does not have to pay for the initial chemotherapy administration (96413).
You asked the Plan to pay for the chemotherapy administration. You say that you would like reconsideration based on the records submitted. The Plan says that the documentation did not indicate the time over which the infusion was administered to the member.
We decided that the Plan has to pay for the additional chemotherapy administration (96417).
The Plan follows Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
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 chemotherapy administration. Our reviewer found the second chemotherapy agent was started at 1613. A volume of 250cc was infused at a rate of 500ml/hr. Therefore, it can be calculated that the infusion ran for thirty minutes, despite the fact that the stop time is not documented. 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 chemotherapy administration have been met. Therefore, we decided that the Plan has to pay for the additional chemotherapy administration.
We also decided that the Plan does not have to pay for the initial chemotherapy administration (96413).
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 initial chemotherapy administration (96413). Our reviewer says that the initial chemotherapy agent was started at 1538. While the administration rate was 100ml/hr, the drug concentration, the infused volume and the stop time are not documented. Therefore, the amount of time of the infusion cannot be calculated or 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 initial chemotherapy administration (96413) have not been met. Therefore, we decided that the Plan does not have to pay for the initial chemotherapy administration (96413).
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the chartered plane transport and related costs provided on
August 24, 2019.
You asked the Plan to pay for these services. You say that this was the only possible way to get home. The Plan
denied your request. The Plan says that the provider is not Medicare participating.
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who
is not enrolled in the Medicare Program.
The services were not provided by a supplier who is enrolled in the Medicare program. Therefore, we decided
that the Plan does not have to pay for the chartered plane transport and related costs provided on August 24,
2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for emergency services provided on July 28, 2019.
You asked the Plan to pay for the emergency services. You say that you would like reconsideration as these services should be covered by the Plan. The Plan denied your request. The Plan says that these services were rendered after your Plan was terminated. 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 emergency services by a contract provider. The file does not show that The Plan provided notice that the emergency services would not be covered. Under Medicare rules, this means the emergency services is considered approved by The Plan. Additionally, there is no evidence that you were disenrolled from the Plan prior to the date of service in question. Therefore, we decided that the Plan has to pay for emergency services provided on July 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient mental health care, for the enrollee.You asked the Plan to pre-approveinpatient mental health care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger toherself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. I am unable to find an individualized treatment plan however the entire chart is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of February 18, 2020 forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient mental health care, for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 14, 2019 by an out of network (OON) provider.You asked the Plan to pay forhospital discharge day management services (99239). You say that you would like reconsideration because the member was being treated inpatient so everything should be included in the hospital's authorization. The Plan denied your request. The Plan says the member has other insurance as their primary and has exhausted mental health day benefits.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 the medical services provided on October 14, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar sacral orthosis and shoulder/arm orthosis providedto the enrollee on November 6, 2019.You asked the Plan to pay forthe orthoses. The Plan denied your request. The Plan says that the documentation submitted did not include an itemized delivery ticket indicating thebilledsupplies were dispensed to the member.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The proof of deliver provided does not indicate what items were supplied.Therefore, we decided that the Plan does not have to pay forthe lumbar sacral orthosis and shoulder/arm orthosis provided to the enrollee on November 6, 2019.