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

 We decided that the Plan does not have to pay for emergency department visit (99285) electrocardiogram, routine ECG with at least 12-leads; interpretation and report only (93010) provided January 5, 2020.  

You asked the Plan to pay for the emergency visit. You say that your claim was submitted within the allotted time frame. Please review the attached documents as proof of untimely filing and forward your claim towards payment. The Plan denied your request. The Plan says the claim was received past the timely filing limitation.  

The Plan follows 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 record shows that a claim for the emergency visit was not filed until August 6, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for emergency department visit (99285) electrocardiogram, routine ECG with at least 12-leads; interpretation and report only (93010) provided January 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services coded as G0453, 95885, 95910, A4556 provided on May 17, 2021.  You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed based on the medical documentation. The Plan denied your request. The Plan says these services have denied correctly.  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, we have confirmed that code G0453 is a column II code to column I code 95940. This claim has not been billed with an appropriate modifier to bypass the edit. Regarding codes 95885 and 95910, these are column II codes to column I code 95861. These claims have a Modifier Indicator of 0 meaning that no modifiers will bypass the edit and these services are never paid separately. Based on the claim submitted, Medicare billing criteria have not been met. Finally, code A4556 has a status code of "P" under the Physician Fee Schedule indicating that no separate payment will be made for this service. Payment for this service is bundled into the payment for the physician service to which it is incident. Therefore, we decided that the Plan does not have to pay for the medical services coded as G0453, 95885, 95910, A4556 provided on May 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 

 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on June 20, 2021.  

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that when the service was provided to you, you were not informed that by using the ambulance to go to the hospital you would be covered. You also say that you called the Plan on July 27, 2021 and were advised that the Plan would pay for the services rendered. The Plan denied your request. The Plan says the trip report confirms that you refused the transport and requested your wife to transport you to the hospital. The Plan also says that without ambulance transport, this claim is not payable per Medicare guidelines.  

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   

The ambulance company did not provide transport services on June 20, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. The record shows that you said it was not necessary to be transported by ambulance and you would like your wife to transport you. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on June 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a stomach emptying study.  You asked the Plan to pre-approve a stomach emptying study. You say that the records provided support the need for the requested study. The Plan denied your request. The Plan says the requested study is not medically necessary.  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 a stomach emptying study. Our reviewer says that a stomach emptying study is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation provided shows that the enrollee has no significant gastroparetic symptoms and is tolerating her prokinetic therapy without difficulty. Our physician reviewer found that the medical necessity for gastric emptying scan has not been demonstrated by the records provided. 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 stomach emptying study have not been met. Therefore, we decided that the Plan does not have to pre-approve a stomach emptying study.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography angiography (CTA) provided on May 28, 2021.  You asked the Plan to pay for the CTA. You say that you would like reconsideration because the requested service is less invasive than other options. The Plan denied your request. The Plan says you do not meet coverage criteria for the requested CTA.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the CTA. Our reviewer says that clinical guidelines for the use of coronary CTA have not been met based on review of the submitted clinical documentation. Our physician reviewer found at this time, coronary CTA would not be considered medically reasonable and necessary in your clinical management.  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 CTA have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography angiography (CTA) provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing provided on July 16, 2021.

You asked the Plan to pay for CxBladder testing. You say that evidence supports this testing as a medically necessary diagnostic service. The Plan denied your request. The Plan says this test is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that CxBladder test code 0013M is not covered by Medicare. 

We looked at the file and Medicare rules. This test is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing provided on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an annual wellness visit provided on August 18, 2021. 

 You asked the Plan to pay for an annual wellness visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this benefit has been exceeded.  

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. 

Based on review of the file, an AWV was provided in March 2021. Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the walk-in tub purchased on April 21, 2021.  You asked the Plan to pay for the walk-in tub. You say that you had a prescription showing that this tub would be beneficial to the enrollee to be able to bathe without the barrier of entry and exit that a regular tub presents. The Plan denied your request. The Plan says this item is not covered under any circumstances. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the walk-in tub purchased on April 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) to the right sacroiliac (SI) joint (64625) provided on August 9, 2021.  

You asked the Plan to pay for RFA to SI joint services. You say that this procedure was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental/investigational and not eligible for payment.  

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 RFA to SI joint services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.   Our physician reviewer found According to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Studies completed say that this procedure does not improve outcomes compared to standard treatment of SI joint pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 RFA to SI joint services have not been met. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation (RFA) to the right sacroiliac (SI) joint (64625) provided on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on May 13, 2021 by a non-participating provider.  

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.  

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 referring provider 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 drug testing provided on May 13, 2021 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit rendered on October 5, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. The file shows that the chiropractor billed procedure code 99202 (office visit). Therefore, we decided that the Plan does not have to pay for the office visit rendered on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a CardioMEMS implant.  

You asked the Plan to pre-approve a CardioMEMS implant. You say that the clinical notes and documentation support the need for this Food and Drug Administration (FDA) approved procedure. The Plan denied your request. The Plan says the requested procedure is investigational. The Plan says that the available evidence does not who that the requested service is effective, nor does it show it provides better health outcomes.  

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 a CardioMEMS implant. Our reviewer says that a CardioMEMS implant is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has severe coronary artery disease, previous coronary artery bypass graft (CABG) surgery and symptoms felt to reflect diastolic heart failure with preserved ejection fraction, ejection fraction 55-60%. The CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with congestive heart failure (CHF.) 

The clinical study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this patient's clinical management.  

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 CardioMEMS implant have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS implant.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Nurtec tablets.  You asked the Plan to pre-approve the Nurtec tablets. The Plan denied your request. The Plan says this medication falls under Part D coverage. The Plan also says that drugs covered under Part D are not eligible for coverage under the 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-approve Nurtec tablets.   Benefits for the Nurtec tablets 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit with a physician (99336) provided on August 11, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for a domiciliary or rest home visit with a physician. You say that it was the nursing facility's responsibility to get authorizations for their patients. The Plan denied your request. The Plan says this provider is not a network provider and the services were not referred by a network provider or rendered in an in-network facility. The Plan also determined that these services were not urgent or emergent, nor were they approved in advance. 

 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 a domiciliary or rest home visit with a physician (99336) provided on August 11, 2021 by an out-of-network (OON) provider.
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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the refraction provided on June 18, 2021.  You asked the Plan to pay for the refraction. You say that you are requesting reimbursement for this service. The Plan denied your request. The Plan says a refraction is not covered with a medical eye exam.   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 it is received during a routine eye exam.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Specifically, the refraction was not performed during a routine eye exam. Therefore, we decided that the Plan does not have to pay for the refraction provided on June 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Repatha Sureclick.  You asked the Plan to pre-approve Repatha Sureclick. You say that the records provided support that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee does not have pharmacy benefits administered under this contract. The Plan says that the enrollee does have TRS-CARE MA which provides its own pharmacy benefits and prescription coverage is provided through CVS Silverscript.  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 Repatha Sureclick.   Benefits for Repatha Sureclick may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.