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

We decided that the Plan does not have to pre-approve endodontic therapy for tooth #'s 6 and 7.
You asked the Plan to pre-approve endodontic therapy. You say that you are disabled, out of work and are in a lot of pain. You say that you cannot afford to pay for the root canals. The Plan denied your request. The Plan says the service is 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. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy for tooth #'s 6 and 7.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on February 1, 2021.
You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99291.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress note for February 1, 2021 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on February 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) provided March 25, 2021.
You asked the Plan to pay for the non-emergency ambulance transportation. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says they did not make a decision within the timeframe.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergency ambulance transportation. Our reviewer says that the requested ambulance services were not medically reasonable and necessary. Our physician reviewer found that the patient is a 75-year-old male with gait abnormality who was transported to the emergency department via ambulance after a fall without incident during transport. The fall was non-traumatic and vitals were stable. In this case, the documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated for this patient on March 25, 2021. Furthermore, the documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The documentation does not support that the ambulance transport was medically reasonable and necessary for the patient. 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 non-emergency ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) provided March 25, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care associated with an approved
elective procedure.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the inpatient care
approved. The Plan denied your request. The Plan says the procedure is currently approved as an ambulatory
procedure. There is no documentation provided to support the expectation the enrollee will require a greater
than 2 midnight stay.
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 acute inpatient hospital care.
Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found that the procedure is currently approved as an ambulatory procedure. There
is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight
stay. The record does not show that at the time of inpatient admission the admitting physician would
reasonably expect that the enrollee's necessary hospital care will 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 pay for the acute inpatient hospital care associated with an approved elective procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive bone growth stimulator (E0748).
You asked the Plan to pre-approve a bone growth stimulator. You say that the bone growth stimulator is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the bone growth stimulator.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days.
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 bone growth stimulator. Our reviewer says that you do not meet Medicare criteria for coverage of a bone growth stimulator. Our physician reviewer found only one level of your spine was fused and not enough time has passed since surgery. This means that the device is not medically necessary for you at this time. 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 bone growth stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-invasive bone growth stimulator (E0748).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no qualifying diagnosis for a group 3 power wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a neurological condition, myopathy, or congenital skeletal deformity causing the mobility deficit. Therefore, a group 3 power wheelchair and the related accessories would not be considered medically reasonable and 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ExoSym kinetic orthosis.

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 the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that an orthosis is covered when specific criteria are met. 

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee currently has a custom ankle-foot orthosis (AFO). There is insufficient evidence in the medical literature to support that the ExoSym kinetic orthosis is more beneficial and effective for the enrollee's condition than the current custom AFO. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the ExoSym kinetic orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pulse oximetry, anoscopy, and 'other outpatient visit' services (94760, 99203, 46600) provided on January 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the services. You say that the enrollee was referred by their daughter, therefore they did not request authorization. The Plan denied your request. The Plan says you did not request authorization, therefore the claim is correctly denied.
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 had network providers available who could have provided 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 pulse oximetry, anoscopy, and 'other outpatient visit' services (94760, 99203, 46600) provided on January 22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) provider.
You asked the Plan to pre-approve a continuation of care with an OON provider. You say that the enrollee has been an established patient with this OON provider for 15 years. You say that he has multiple hematology problems and sees this provider frequently. You say that he knows and trusts this OON provider. The Plan denied your request. The Plan says there are network providers within a reasonable distance from the enrollee that can provide the services needed.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 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 continuation of care with an OON provider. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has polycythemia. The record indicates that the polycythemia is stable. The enrollee has recently had a gastrointestinal bleed and also requires a pulmonary consult. The record indicates that the specialist is functioning as the enrollee's primary care physician in this case and is referring the enrollee to other specialists. The enrollee is not receiving active care from the doctor in a hematology role. 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 continuation of care with an OON provider have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291-25) provided on December 25, 2020, and subsequent hospital care (99233) provided from December 26, 2020, through December 28, 2020.
You asked the Plan to pay for critical care services and subsequent hospital care. You say that you would like reconsideration based on the medical records provided. The Plan denied your request. The Plan says the billed services are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 99291-25 and 99233 are not supported in the medical record. Specifically, the medical records did not document the total time spent providing critical care services on December 25, 2020. There were no medical records provided to support the billing of code 99233 from December 25, 2020, through December 28, 2020. Based on this information, we decided that Medicare rules for coverage of critical care services and subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291-25) provided on December 25, 2020, and subsequent hospital care (99233) provided from December 26, 2020, through December 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
You asked the Plan to pre-approve a portable ventilator. You say that the absence of respiratory support would be detrimental long term. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in AVAPS mode that could equally be delivered by BiPAP is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 portable ventilator. Our reviewer says that a portable ventilator is not medically reasonable and necessary for the enrollee. The enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The enrollee was hypercarbic and responded to treatment with Bilevel positive airway pressure (BiPAP) with Average volume-assured pressure support (AVAPS) setting.
The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator. 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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on April 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care 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 had network providers available who could have provided 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 subsequent nursing facility care services provided on April 6, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm for the enrollee.
You asked the Plan to pre-approve Aduhelm. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that the stage of the enrollee's dementia appears to be moderate.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA approved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Aduhelm. Our reviewer says that
Aduhelm is not medically reasonable and necessary for the enrollee. The record does not contain objective
primary source documentation of imaging and cognitive testing. The medical records themselves are
insufficient to establish a diagnosis of Alzheimer's disease and suggests that the requested drug is being
prescribed at patient family's request. Our physician reviewer found that the enrollee's condition does not meet
criteria for coverage of Aduhelm.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aduhelm for the enrollee.
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically
necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 the complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. While the documentation does support a need for physical
and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation
program.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.

You asked the Plan to pre-approve inpatient hospital care. You say that The Plan denied your request. The Plan says the enrollee will not require a greater than 2 midnight stay.

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 inpatient hospital care. Our physician reviewer found that the enrollee is medically stable. The records do not show the enrollee has a condition that warrants an inpatient stay for surgery. The record does not show that the enrollee's necessary hospital care will 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 inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies, material, and clinical staff time need due to the pandemic for services provided on May 12, 2021, billed with code 99072.
You asked the Plan to pay for the items/services as billed. You say that this code was approved by the American Medical Association and must be acknowledged by the Plan. The Plan denied your request. The Plan says there is no additional payment made by Medicare when this code is reported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Code 99072 has a status indicator of "B" on the Physician Fee Schedule. This means that payment is always bundled in payment for other services provided on the same date. Based on this information, we decided that Medicare rules for coverage of the items/services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies, material, and clinical staff time need due to the pandemic for services provided on May 12, 2021, billed with code 99072.