Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device
(E0601) and a monitoring feature (A9279) provided on April 1, 2021.
You asked the Plan to pay for a CPAP device and a monitoring feature. You say that these items are supported
in the records. The Plan denied your request. The Plan says these items cannot be paid as billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. The proof of
delivery shows a shipping date of March 30, 2021 and a delivery date of April 5, 2021, neither of which is the
billed date of service. The record shows that the Plan made several attempts to obtain the necessary
documentation without success. Therefore, we decided that the Plan does not have to pay for a continuous
positive airway pressure (CPAP) device (E0601) and a monitoring feature (A9279) provided on April 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

You asked the Plan to pay for the transportation services. You say that you should have been told that your
wife could have taken you. You say that you were taken to your cardiologist. You also say that it was
confirmed that you had a heart attack. The Plan denied your request. The Plan says the non-emergency
ambulance transport was not medically necessary.
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 transportation services. Our reviewer
says that the transportation services were not medically necessary. Our physician reviewer found the
documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi,
private car, or other type of vehicle) were contraindicated for you on May 31, 2021. The reviewer found that
the documentation does not support that you needed the expertise, services and lifesaving and life-sustaining
equipment that only a fully-equipped ambulance can provide for safe transport on May 31, 2021. Therefore, the
reviewer found that the documentation does not support that the ambulance transport on May 31, 2021 was
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 transportation services have not been met. Specifically, the file does not
support that other means of transport were contraindicated. Therefore, we decided that the Plan does not have
to pay for the ambulance service, advanced life support, non-emergency transport (A0426) and non-covered
ground mileage (A0888) provided on May 31, 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 enrollee requires close monitoring to ensure she is able to return to a new functional baseline. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care.
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 physician reviewer found that in this case, the enrollee was admitted to the acute care hospital after suffering polytrauma from a motor vehicle crash. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. Therefore, the requested services are not medically reasonable or necessary 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 7, 2021.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not include definitive laboratory results for 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95885, 95907, 95927, 95937, 95955) provided on May 11, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot be verified.
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of codes 95885, 95907, 95927, 95937, and 95955, is not supported by the records provided. Our reviewer found that for code 95885, a nerve conduction study is required to report this procedure, as a nerve conduction study was not documented in the technical report this procedure would not be covered. For code 95907, the technical report
does not include documentation of a nerve conduction study to include measurements of amplitude, latency, and conduction velocity. For code 95927, the technical report does not include documentation of stimulation of any/all peripheral nerves or skin sites, recording from central nervous system to verify procedure, was performed. For code 95937, the technical report does not include documentation of neuromuscular junction testing. For code 95955, this is an incorrect code to report for "real-time" monitoring. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report. Any additional EEG would be included in the correct intraoperative monitoring procedure code. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (95885, 95907, 95927, 95937, 95955) provided on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. 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 follows Medicare rules. Medicare rules say that ventilators (E0465, E0466, and E0467) are covered
for certain conditions.
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 the services are not medically necessary. Our physician reviewer found use of a portable ventilator to
deliver ventilatory support via settings that would be equivalent to a bilevel positive airway pressure (BiPAP)
device with average volume-assured pressure support is reported to be denied as not reasonable and necessary
according to the coverage criteria.
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.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health care visits.
You asked the Plan to pre-approve home health care. You say that the enrollee continues to require care from a skilled nurse and needs assistance with personal care and activities of daily living. The Plan denied your request. The Plan says the denial of authorization for home health care is correct.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health care. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer found there is no documentation that skilled nursing care beyond what the Plan has already approved is required to effectively provide treatment, care, and/or services that are medically necessary. The records do not document any acute or unstable medical conditions or changes in medication or treatment that would necessitate further skilled nursing beyond what the Plan already approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health care visits.
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 you need care in an IRF so that you can function on your own. You say that you are very weak and need to get your strength back. The Plan denied your request. The Plan says IRF care 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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for rhabdomyolysis, syncope, a fall, respiratory failure, and chronic obstructive pulmonary disease (COPD.) The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal nerve ablation procedure (C9752).

You asked the Plan to pre-approve the spinal procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is not covered.

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 the spinal procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found radiofrequency ablation of the basivertebral nerves is considered experimental at this time and is not covered.

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 spinal procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal nerve ablation procedure (C9752).
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 enrollee will benefit from inpatient rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the enrollee does not require an interdisciplinary team approach for rehabilitation care.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for non-operative management of pelvic fractures after a fall. Her medical problems are stable.
The enrollee does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While she has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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 a crown (D2740) and a core buildup including any pins when required (D2950) provided on August 2, 2021.
You asked the Plan to pay for a crown and a core buildup. You say that you were advised by the Plan that your dental services were going to be covered. You also say you should not be responsible for the cost. The Plan denied your request. The Plan says upon review of the call you made to the Plan regarding crowns, you were advised that codes D2753 and D2794 were covered. The Plan also says that the requested codes on the claim are not covered services with your Plan.
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 pay for a crown (D2740) and a core buildup including any pins when required (D2950) provided on August 2, 2021.
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 inpatient rehabilitation services are medically necessary to ensure the enrollee has a safe and sustainable discharge home. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the services they need in an alternate setting.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 risk assessment and documentation (D0602) and intraoral
radiographic images (D0210) provided by an out-of-network provider on August 30, 2021.
You asked the Plan to pay for risk assessment and documentation and intraoral radiographic images. You say
that you would like the Plan to pay for this. The Plan denied your request. The Plan says D0602 is not a
covered benefit. The Plan says that D0210 has already been exhausted.
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, D0602 is not among those covered
under this benefit. D0210 was exhausted on May 27, 2021.Therefore, we decided that the Plan does not have to
pay for risk assessment and documentation (D0602) and intraoral radiographic images (D0210) provided by an
out-of-network provider on August 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ultrasound studies of the arms and legs
(93923, 93923-59) and the autonomic nervous system testing (95923) provided on April 14, 2021.
You asked the Plan to waive the copayments for the ultrasounds and nervous system testing. You say that your
provider told you these services would be done at no cost to you. The Plan denied your request. The Plan says
this claim was processed correctly, and your copayments were assessed in accordance with your contract.
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 $150
copayment for Medicare-covered radiological diagnostic services and a $25 copayment for Medicare-covered
non-radiological diagnostic services. Providers may ask you for more than one cost share payment if you get
more than one service at an appointment.
You have been asked to pay a $150 copayment for the ultrasounds and a $25 copayment for the nervous system
testing. Ultrasounds are considered radiological diagnostic services and the nervous system testing is
considered a non-radiological diagnostic test. 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 copayments for the
ultrasound studies of the arms and legs (93923, 93923-59) and the autonomic nervous system testing (95923)
provided on April 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (93005), the transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location (R0070), the set-up of portable x-ray equipment (Q0092), and the x-ray examinations of the chest (71046 x 2) rendered by the out-of-network (OON) provider on April 15, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (93005), the transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location (R0070), the set-up of portable x-ray equipment (Q0092), and the x-ray examinations of the chest (71046 x 2) rendered by the out-of-network (OON) provider on April 15, 2021.