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

We decided that the Plan does not have to pre-approve a routine transportation trip totaling 157 miles.
You asked the Plan to pre-approve a 157-mile routine transportation trip. You say that you need this transportation so you can have surgery. The Plan denied your request. The Plan says a trip of this length is not covered under your 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 routine transportation up to 50 miles per trip. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. The trip you have requested exceeds 50 miles. Therefore, we decided that the Plan does not have to pre-approve a routine transportation trip totaling 157 miles.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and dental extraction to be provided by
an oral surgeon.
You asked the Plan to pre-approve a consultation and dental extraction to be provided by an oral surgeon. 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 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. While the plan covers extractions, the extractions are only covered
when performed by a participating general dentist. Services from an oral surgeon are not covered. Therefore,
we decided that the Plan does not have to pre-approve a consultation and dental extraction to be provided by an
oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN).
You asked the Plan to pre-approve the requested services. You say that the enrollee does not have a permanent condition of the alimentary tract, and has not failed a trial of tube infusion to provide nutrition directly to the stomach. The Plan denied your request. The Plan says it is very difficult for the enrollee to chew and eat regular foods.
The Plan follows Medicare rules. Medicare rules say that the documentation must be clear and precise to verify that the beneficiary suffers from a permanently impaired gastrointestinal tract and that there is insufficient absorption of nutrients to maintain adequate strength and weight. 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 requested services. Our physician reviewer found that there is no evidence that the enrollee has an anatomic inability to eat, has a physiologic inability to digest/absorb, is in need of bowel rest, or is severely malnourished/underweight. As such, the request for IDPN is not medically necessary or reasonable. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 9, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 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 tests at issue in this appeal, the laboratory services, were 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 the laboratory services provided on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management (99239) provided on August 23, 2019. You asked the Plan to pay for discharge day management. You say that this should be paid. The Plan denied your request. The Plan says the records do not support this code. 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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, this is a time-based code and the submitted medical records do not document the time spent on discharge day management on August 23, 2019. Based on this information, we decided that Medicare rules for coverage of discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for discharge day management (99239) provided on August 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220) and the crown (D2740) provided on November 14, 2019 by an out of network provider.
You asked the Plan to pay for the dental services. You say that you were not aware of the requirement that treatment plans over $500 need prior authorization. You also say that the office assured you that the plan would cover the services. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that dental services that you receive out of network are not covered.
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 the periapical x-ray and crown are listed as covered services, they are not covered when they are performed out of network. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220) and the crown (D2740) provided on November 14, 2019 by an out of network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for androgen receptor (AR) gene analysis testing provided on November 18, 2019.
You asked the Plan to pay for AR gene testing. You say that the treating physician ordered this test to determine if there was a more effective treatment for the enrollee's condition. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician for this testing was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice that this testing would not be covered. This test was not excluded from Medicare coverage for this date of service and place of service. Without this information, we cannot determine whether the lab order made constituted plan-directed care, which would justify coverage of this test. Therefore, the Plan has not shown that its decision to deny payment for this claim is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for androgen receptor (AR) gene analysis testing provided on November 18, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure (95999) provided on June 24, 2019.
You asked the Plan to pay for this procedure. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that Medicare guidelines say that this service is considered a bundled procedure as the cost is included in the cost of the primary procedure.
The Plan must follow Medicare rules. Medicare rules say that services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code.
In this case, we have confirmed that code 95999 has a bundled relationship with code 95941 and cannot be paid as billed. Code 95999 cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure (95999) provided on June 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF service. You say that you do not feel comfortable being on your own.
The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.
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 SNF service. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a
Skilled Nursing Facility (SNF) setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF service have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services from December 7, 2019 through December 9, 2019.
You asked the Plan to pay for the services. You say that you are asking for DRG level of payment. The Plan denied your request. The Plan says there is no additional information that justifies this request.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. In this case, you billed the services provided December 7, 2019 through December 9, 2019 with DRG 062. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our physician reviewer found the records reviewed support the diagnosis of an ischemic stroke with thrombolytic agents utilized. Complications and comorbidity are not supported. The DRG request is denied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG 062. Therefore, we decided that the Plan does not have to pay for the services from December 7, 2019 through December 9, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Supartz FX.
You asked the Plan to pre-approve Supartz FX. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for Supartz FX is correct, because the Plan requires a trial of Durolane, Gelsyn-3, and Synvisc before it will approve Supartz FX. The Plan also says that your treating provider has since requested Synvisc which is a Plan-covered drug that does not require authorization. Please contact the Plan for more information about this new request.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Supartz FX. Our reviewer says that you do not meet the Medicare criteria for use of Supartz FX. Our physician reviewer found the documentation does not show that you have tried and failed the Plan's preferred drugs of Durolane, Gelsyn-3, or Synvisc. The documentation does not show that these drugs would likely be less effective and/or have adverse effects for you.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Supartz FX.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from January 9, 2019 to
December 18, 2019.
You asked the Plan to pay for chiropractic services. You say that these services are covered. The Plan denied
your request. The Plan says the denial of payment for these services is correct, because the claims for dates of
service in January 2019 were not submitted within the timely filing limit and the visits from February 8, 2019
to December 18, 2019 are not covered by Medicare.
The Plan must follow 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 rules say that the only
chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
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 chiropractic services Our reviewer says that
these services do not meet the Medicare criteria for coverage. Our physician reviewer found you did not have a
subluxation demonstrated by X-Ray or physical examination. The submitted office visit notes reveal such
findings as some restriction with range of motion, pain in lower back, and lower back tenderness and stiffness
which do not reveal evidence of subluxation according to Medicare guidelines. Thus, these chiropractic
treatments are neither supported nor allowed per Medicare guidelines. These services were maintenance
therapy.
We looked at this physician's review, the file, and Medicare rules. The claims for dates of service January 9,
2019 and January 23, 2019 were not submitted to the Plan until February 5, 2020. This means that more than 1
calendar year had passed before these claims were filed. The services from February 8, 2019 to December 18,
2019 do not meet Medicare's criteria or the Plan's rules for coverage of chiropractic services. Based on this
information, we decided that Medicare rules for coverage of chiropractic services have not been met.
Therefore, we decided that the Plan does not have to pay for chiropractic services provided from January 9,
2019 to December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for refraction services (92015) provided December 9, 2019.
You asked the Plan to pay for the refraction services. You say that you received a payment of $45 for service
code 92014 eye exam but not for service code 92015 refraction. You thought this was covered up to $75 for the
eye exam and refraction. The Plan denied your request. The Plan says that this service is not payable by the
Plan.
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. The Plan covers these services when provided as a part of a routine eye exam. The plan had
reimbursed for the routine eye exam. Therefore, the refraction is covered per the plan benefits.
We looked at the file and the Plan's rules. refraction and dilation is included with a routine eye exam Based on
this information, we decided that the Plan's rules for coverage of the refraction services have been met.
Therefore, we decided that the Plan has to pay for refraction services (92015) provided December 9, 2019.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on December 30, 2018.
You asked the Plan to pay for the services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the claim was not received within the standard timely filing limit and does not meet the minimum requirements for proof of payment.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that the Plan rules for coverage of the services have not been met. The original request was received on December 23, 2019 and was denied due to: "BDF- Receipt does not show payment method for service received/item purchase." Please note, the original request did not indicate the method of payment as cash, which you corrected on your second submission. The original submission was also past timely filing. Therefore, we decided that the Plan does not have to pay for the services provided on December 30, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program in an IRF as you cannot tolerate and make progress as expected. IRF admission is not medically necessary based on your current functional status, ability and medical stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for CPT code 37242 provided on January 29, 2020.
You asked the Plan to pay for CPT code 37242. You say that the medical records support the billing of CPT code 37242. The Plan denied your request. The Plan says that the medical records do not support the billing of CPT code 37242.
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 37242 is Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (e.g., congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms). 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 CPT code 37242. Our reviewer says that the medical records support the billing of CPT code 37242. Our physician reviewer found the enrollee was undergoing endovascular repair of an abdominal aortic aneurysm with the limbs of the endograft extending into the external iliac arteries. There is satisfactory documentation that the left internal iliac artery was cannulated, angiography performed, and the left internal iliac artery embolized with Penumbra coils. The endograft limb was then extended into the external iliac artery. The work of the left internal iliac artery embolization at the time of endovascular repair of the aortic aneurysm is separately billable and correctly coded using CPT code 37242. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 37242 have been met. Therefore, we decided that the Plan has to pay for CPT code 37242 provided on January 29, 2020.