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

We decided that the Plan does not have to pay for the supplies used during air ambulance transport provided on July 20, 2019.You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that Medicare does not make separate payment for ambulance supplies.Medicare rules say that payment under the fee schedule for ambulance services covers both the transport of the beneficiary to the nearest appropriate facility and all items and services associated with such transport; and does not include a separate payment for items and services furnished under the ambulance benefit. The Plan follows the same rules.Therefore, we decided that the Plan does not have to pay for the supplies used during air ambulance transport provided on July 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansayscare can be provided in the current inpatient hospital.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 the enrollee is currently undergoing treatment at an ACH for COVID-19. The enrollee required intubation/ventilation and was started on hemodialysis. The enrollee recently received a tracheotomy and feeding tube. He is noted to be tolerating a tracheotomy collar. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long termcare needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plandoes not havetopre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthoses (L1851) provided to the enrollee on October 17, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the provider didn't bill the code with an RT/LT in order to bill the 2 units of service.
The Plan must follow Medicare rules. Medicare rules say that LT/RT modifiers must be used when billing for orthosis base codes. We looked at the file and Medicare rules. The provider did not bill in accordance with Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthoses (L1851) provided to the enrollee on October 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from December 3, 2019 through December 6, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you cannot afford the copayment. The Plan denied your request. The Plan says the copayment applied 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 $372 copayment each day for days 1-5, per admission. You have been asked to pay a $1,116 copayment for the inpatient stay. ($372/day x 3 days = $1,116). The inpatient stay falls within the "Inpatient hospital care" 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 inpatient stay provided from December 3, 2019 through December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (CPT K0861) and accessories (CPT E2361, E1028, E2377, E1007, E2311, E0955, E1028, E1012, and E2603).
You asked the Plan to pre-approve the group 3 power wheelchair and accessories. You say that the requested equipment is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of the requested items.
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 group 3 power wheelchair and accessories. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has deficits in mobility and in mobility related activities of daily living due to a diagnosis of multiple sclerosis. However, the enrollee is not noted to have an inability to utilize a lesser device. The records provided do not document a significant incoordination or motor weakness/atrophy. 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 group 3 power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (CPT K0861) and accessories (CPT E2361, E1028, E2377, E1007, E2311, E0955, E1028, E1012, and E2603).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion pump supplies provided from September 21, 2019 to September 24, 2019.
You asked the Plan to pay for infusion pump supplies (A4222). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee's issue is not a covered diagnosis for external infusion pump and the medication is not on the list of approved medications suitable for an external infusion pump.
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 infusion pump supplies (A4222). Our reviewer says that the items were not considered medically reasonable and necessary in this case. Our physician reviewer found parenteral administration of the drug in the home is reasonable and necessary. An infusion pump is not necessary to safely administer the drug. Systemic toxicity or adverse effects of the drug are not unavoidable without infusing it at a strictly controlled rate as indicated in the Physicians Desk Reference, or the U.S. Pharmacopeia Drug Information. Neither all criteria 1 or 2 in Local Coverage Determination (LCD): External Infusion Pumps (L33794) is met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infusion pump supplies (A4222) have not been met. Therefore, we decided that the Plan does not have to pay for infusion pump supplies provided from September 21, 2019 to September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on April 3, 2019.
You asked the Plan to pay for the laboratory testing. 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.
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 laboratory testing at issue in this appeal 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 laboratory testing provided on April 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 23, 2019.
You asked the Plan to pay for the 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.
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 laboratory testing at issue in this appeal 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 laboratory services provided on April 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on August 19, 2019.
You asked the Plan to pay for the orthoses. 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 for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on August 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Acetaminophen/codeine tablets.You asked the Plan to pre-approve Acetaminophen/codeine tablets. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Acetaminophen/codeine tablets are not covered under the enrollee's 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 pre-approveAcetaminophen/codeine tablets.Benefits for Acetaminophen/codeine tabletsmay 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 pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 27, 2019.You asked the Plan to pay for the orthoses. 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. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not haveto pay forthe amalgam (D2160) for tooth # 28 provided on January 13, 2020.You asked the Plan to pay forthe dental service. You say that this is the first time you have received this service under you plan. You also say that you do not believe you had any particular tooth work done within a 36 month period.The Plan denied your request. The Plan says the frequency limit has been exceeded.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 and amalgams are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for an amalgam on tooth # 28 thatyou received on August 7, 2018.Therefore, we decided that the Plan does not have to pay forthe amalgam (D2160) for tooth # 28 provided on January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveankle foot orthosis, addition to lower extremity, lacer molded to patient, and addition to lower extremity orthosis.You asked the Plan to pre-approveankle foot orthosis (L1940), addition to lower extremity lacer molded to patient (L2330), and addition to lower extremity orthosis(L2820).You say that you are in pan and you need ankle foot orthoses.The Plan denied your request. The Plan says criteria is not met for the orthoses.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 ankle foot orthosis (L1940), addition to lower extremity lacer molded to patient (L2330), and addition to lower extremity orthosis(L2820).Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of tibial tendinitis. Review of the submitted medical records does not include documentation to support the medial necessity of a custom fabricated orthosis.  Without this, medical necessity cannot be determined and the denial is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ankle foot orthosis (L1940), addition to lower extremity lacer molded to patient (L2330), and addition to lower extremity orthosis(L2820) havenot been met.Therefore, we decided that the Plan does not have to pre-approveankle foot orthosis, addition to lower extremity, lacer molded to patient, and addition to lower extremity orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department services coded 99283 provided on November 25, 2019.You asked the Plan to pay forthe emergency department services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.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 99283 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination ofcare with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity.We find that CPT code 99283 is not supported in the medical record. Specifically, some codes indicate laterality, specifying whether the condition occurs on the left, right, or bilateral. It is not appropriate to report unspecified, or left and right diagnosis codes when a more specific code is available. Based on this information, we decided that Medicare rules for coverage of the emergency department services have not been met.Therefore, we decided that the Plan does not have to pay forthe emergency departmentservices coded 99283 provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve telemedicine evaluation with a pain specialist for medication refills.
You asked the Plan to pre-approve the pain medicine evaluation. You say that you need refills for your pain medication and your PCP will not prescribe these via telemedicine so you need to be able to been seen by a pain specialist. The Plan denied your request. The Plan says your PCP was contacted and it was confirmed that you can be seen via telemedicine and can be prescribed your medication. As such, there is no need for a visit with a pain specialist.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Based on the documentation submitted, you are seeking evaluation for a refill on a medication. You believed that you needed to see the specialist since your PCP would not provide this; however, the Plan confirmed that your PCP is able to do this. This means that evaluation by a pain specialist would exceed your medical need when it can be addressed by your PCP. Therefore, we decided that the Plan does not have to pre-approve telemedicine evaluation with a pain specialist for medication refills.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided to the enrollee on May 21, 2019.
You asked the Plan to pay for this service. You say that the Plan should pay this claim. The Plan denied your request. The Plan says due to the enrollee's hospice election, the provider must submit the claim to Original Medicare first and then to the Plan once it has been addressed by Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospital services provided to the enrollee on May 21, 2019.
Sincerely,
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397, L2810) provided to the enrollee on September 18, 2019.You asked the Plan to pay forthe orthoses. 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 rules say 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. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, medical records do not support a prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was performed. The information submitted does not confirm that Medicare coverage criteria have been met.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397, L2810) provided to the enrollee on September 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 Xifaxan.
Benefits for these services 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 the oncology gene expression services coded 81545 provided on October 30, 2019.
You asked the Plan to pay for the oncology gene expression services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the billed code was previously processed for this date of service. Therefore, this billed code is a duplicate. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the oncology gene expression services coded 81545 provided on October 30, 2019.