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

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says additional trips in excess of fifty-two (52) one-way trips are non-covered by the health Plan.
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. We looked at your request, the records in the case file, and the rules. The file shows that the Plan benefit covers
up to fifty-two (52) one-way trips per year and you have used fifty (50) trips. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve VRT to be provided by the requested out-of-network
provider.

You asked the Plan to pre-approve VRT to be provided by the requested out-of-network provider. The Plan
denied your request. The Plan says you must receive your care from a network provider. In most cases, care
you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be
covered.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve VRT to be
provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of residual tooth roots (cutting procedure) (D7250), therapeutic parenteral drug, single administration (D9610), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223).
You asked the Plan to pre-approve the removal of residual tooth roots, therapeutic parenteral drug and general anesthesia. You say that the procedure is warranted and medically necessary. The Plan denied your request. The Plan says these services are not covered under your benefits.
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 the
removal of residual tooth roots (cutting procedure) (D7250), therapeutic parenteral drug, single administration (D9610), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223).
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 meets LTACH criteria and needs daily physician assessments which can be performed at the LTACH level. The Plan denied your request. The Plan says under Medicare, the request 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 that there is no documentation provided indicating medical necessity for the requested LTACH services. 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 acute care hospital where he 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 provide additional routine transportation trips.

You asked the Plan to provide additional routine transportation. You say that you need these transportation
services to get to your appointments. The Plan denied your request. The Plan says 48 trips are covered under
your routine transportation benefit. You have used all of your available trips, and additional transportation is
not covered.

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 a maximum of 48 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided on February 19, 2021.

You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully support and justify billing code 99072. You say that the daily notes clearly show the kind of precautions taken and the code should be reprocessed for prompt payment. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.

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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two preventive procedures (D1999 x2) provided on May 11, 2021, and May 27, 2021.
You asked the Plan to pay for the preventive procedures. You say that this treating provider was given to you by the Plan as an in-network provider. The Plan denied your request. The Plan says this service is 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, 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 the two preventive procedures (D1999 x2) provided on May 11, 2021, and May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for administration of the COVID-19 vaccine provided on March 31, 2021.

You asked the Plan to pay for immunization administration of the COVID-19 vaccine (0001A). You say that this vaccine should be covered under the enrollee's current plan. The Plan denied your request. The Plan says COVID-19 vaccine administration claims are to be submitted to Original Medicare.

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 the claim should be submitted to the MAC for the enrollee's jurisdiction. Based on this information, we decided that Medicare rules for coverage of immunization administration of the COVID-19 vaccine (0001A) have not been met. Therefore, we decided that the Plan does not have to pay for administration of the COVID-19 vaccine provided on March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway pressure (CPAP) machine (E1399).

You asked the Plan to pre-approve a CPAP machine back up battery. You say that the electricity is constantly going out and you need the backup battery. The Plan denied your request. The Plan says the requested item is not a covered benefit.

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 pre-approve a backup battery for a continuous positive airway pressure (CPAP) machine (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0800).

You asked the Plan to pre-approve a power scooter. You say that the item is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for the requested item.

The Plan follows Medicare rules. Medicare rules say that a power operated vehicle [POV] is covered if all the following are met: 

A. the beneficiary has mobility limitation that significantly impairs his/her ability to participate in one or more mobility related activities of daily living; 
B. the beneficiary's mobility limitation cannot be sufficiently and safely resolve by the use of appropriately fitted cane or walker, C. the beneficiary does not have sufficient upper arm function to self-propel an optimally configured manual wheelchair, 
D. the beneficiary is able to safely transfer to and from a power operated vehicle and operate the vehicle appropriately, 
E. the beneficiary's mental and physical capabilities are sufficient for safe mobility using a power operated vehicle, 
F. the beneficiaries home provides adequate access for the use of a power operated vehicle inside the home, and 
G. the beneficiary's weight is appropriate for the requested power operated vehicle. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power scooter have not been met. Specifically, there is no documentation indicating the beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided or that the POV is for the purpose of use inside the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0800).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81479, 81225, 81226, 81227, 81355, and 81401 provided on March 12, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 81479, 81225, 81226, 81227, 81355, and 81401 are not supported in the medical record. Specifically, the documentation shows that the enrollee had molecular pharmacogenetic testing. When a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same molecular pharmacogenetic panel. A panel constitutes a single procedural service, so only one code must be submitted for the panel. More than one code was billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81479, 81225, 81226, 81227, 81355, and 81401 provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel coded 81407, 81408, and 81479 and the laboratory services coded 81401, 81403, 81404, 81405, 81406, and 81185 provided on January 5, 2021.
You asked the Plan to pay for the cardiovascular risk assessment panel and the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Cardiovascular risk assessment panels are only covered for certain indications.
Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129 and L36362 to support their denial. However, LCD L36139, L36129 and L36362 are not valid for the provider's billing state of Florida. Therefore, we are unable to use LCD L36139, L36129 and L36362 to substantiate our decision.
While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. This means payment for codes 81407, 81408, and 81479 are not payable as billed.
We find that CPT codes 81401, 81403, 81404, 81405, 81406, and 81185 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment panel and the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel coded 81407, 81408, and 81479 and the laboratory services coded 81401, 81403, 81404, 81405, 81406, and 81185 provided on January 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre 14 day sensor kit.

You asked the Plan to pre-approve the Freestyle Libre 14 day sensor kit. You say that the item is medically necessary. The Plan denied your request. The Plan says the enrollee does not use insulin with at least three daily injections.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the Freestyle Libre 14 day sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 14 day sensor kit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) and
debridement, subcutaneous tissue (includes epidermis and dermis, if performed) (11042) provided on
September 20, 2020, by an OON provider.

You asked the Plan to pay for the nursing facility care. You say that the medical records provided support the
necessity of the services in dispute. The Plan denied your request. The Plan says enrollee's must receive their
medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent
services with non-contracted providers require prior authorization before services being rendered.

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 (99308) and
debridement, subcutaneous tissue (includes epidermis and dermis, if performed) (11042) provided on
September 20, 2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62323, 20610, J3301, J1030, J2250, J3010) and outpatient hospital services provided on May 5, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for injections and outpatient hospital services. You say that the ordering physician's office failed to obtain a referral for the denied service, and you should not be penalized. The Plan denied your request. The Plan says services were provided 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 injections (62323, 20610, J3301, J1030, J2250, J3010) and outpatient hospital services provided on May 5, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on May 4, 2021.

You asked the Plan to pay for the outpatient hospital 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 as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. Medicare says that the OCE will return to the provider any claim that reports a HCPCS code for a procedure assigned to a device-intensive APC, for which the procedure requires the implantation of a device that does not also report at least one device HCPCS code required for that procedure. In this case, Medicare procedure/device coding requirements have not been met as procedure code 19281 must be reported with a qualifying device code. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on May 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prochlorperazine, 10 mg tablet.

You asked the Plan to pre-approve prochlorperazine. You say that the enrollee has tried and failed Zofran. You also say that the medication is necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

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 prochlorperazine, 10 mg tablet.

Benefits for prochlorperazine 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on May 18, 2021, through May 19, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like these services fully reimbursed due to medical necessity. The Plan denied your request. The Plan says this level of care was not medically necessary.
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 chest pain was resolved prior to admission. Our physician reviewer found by the time of admission, the pain resolved suggesting no need for a hospital stay that would likely cross 2 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 provided on May 18, 2021, through May 19, 2021.