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

 We decided that the Plan does not have to pre-approve an Emgality pen.  You asked the Plan to pre-approve Emgality pen. You say that the requested drug is medically necessary for the enrollee's condition. 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 an Emgality pen.   Benefits for Emgality pen 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the routine disposable supplies (A0398), fixed wing air transport (A0430), and fixed wing air mileage (A0435) provided on September 17, 2019.    

You asked the Plan to pay for the supplies, fixed wing air transport, and air mileage. You say that the enrollee was transported for services which were not available at the sending facility and/or locally. You also say that the enrollee's condition warranted and required the emergency air ambulance transport. The Plan denied your request. The Plan says the information provided at the time of the appeal does not support criteria for air ambulance transport for non-emergency psychiatric care. The Plan also says that the enrollee was hemodynamically stable.  

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.   

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 supplies, fixed wing air transport, and air mileage. Our reviewer says that the air transport was not medically reasonable and necessary. Our physician reviewer found there is no documentation that the patient suffered from an illness or injury that contraindicated transportation by any means other than air ambulance. Our reviewer found that there is no documentation that the patient's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously endangered the patient's health. The records document stable vital signs on 2-liter nasal cannula oxygen and an overall stable condition on transfer. Our physician reviewer also found that the documentation does support that the transferring hospital did not have adequate facilities to provide the medical services needed by 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 supplies, fixed wing air transport, and air mileage have not been met. Therefore, we decided that the Plan does not have to pay for the routine disposable supplies (A0398), fixed wing air transport (A0430), and fixed wing air mileage (A0435) provided on September 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70544 provided on August 19, 2021.

You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date of service. The Plan denied your request. The Plan says procedure code 70544 is incidental to procedure code 70551, which was already paid for the same date of service.

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 procedure code 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70544 provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for emergency anesthesia (99140) provided on March 9, 2021.  

You asked the Plan to pay for the emergency anesthesia. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99140 has a status indicator of B and payment for this service is always bundled.  

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 code 99140 is not supported in the record. Specifically, CPT code 99140 has a status indicator of B. This means that the payment for this service is always bundled into the payment for another service or procedure. Based on this information, we decided that Medicare rules for coverage of the emergency anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for emergency anesthesia (99140) provided on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services provided to the enrollee on April 1, 2021.  You asked the Plan to pay for lab services provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says the original denial for codes 81242, 81250, 81363, 81364, 81400, 81401, 81403-3units, 81404-5units, 81405-2units, 81406-2units, 81407, and 81408-2 units has been upheld   with a new denial reason. Insufficient records were provided to support this claim. The Plan states that six attempts to obtain the ordering provider's progress notes were requested between August 3, 2021 and October 25, 2021.  The Plan states the denial is being upheld due to the provider not submitting progress notes and or lab results that are needed in order to determine the clinical utility of the testing.   The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary specific documentation to support the services billed. The records provided are lacking a valid order. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on April 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.  You asked the Plan to pre-approve PET scan. You say that your urologist is trying to rule out cancer. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not meet criteria for a PET scan.  The Plan must follow Medicare rules. Medicare rules say that PET 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 pre-approve PET scan. Our reviewer says that you do not meet the Medicare criteria for a PET scan. Our physician reviewer found the record does not indicate that you have cancer. The requested scan is to screen you for cancer. This does not satisfy the Medicare 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on June 16, 2021.

You asked the Plan to pay for this equipment. You say that this is a common piece of equipment provided during outpatient surgery. The Plan denied your request. The Plan says this claim was not submitted with an appropriate place of service code.

The Plan must follow Medicare rules. The rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility.

Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on June 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Contour Next brand diabetes testing meter.

You asked the Plan to pre-approve Contour Next. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the Plan requires a trial with the Plan's preferred brand of Lifescan or a reason that the enrollee cannot use a Lifescan brand monitor.

The Plan must follow Medicare rules. Medicare rules say that plan may limit coverage to certain brands, items, and supplies. The enrollee's contract with the Plan says that the Plan will only cover Lifescan brand diabetic testing strips and monitors. 

We looked at the file and Medicare rules. The requested Contour Next monitor is not the Plan's preferred brand of diabetic testing monitor. Based on this information, we decided that Medicare rules for coverage of Contour Next have not been met. Therefore, we decided that the Plan does not have to pre-approve a Contour Next brand diabetes testing meter.
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 does not meet criteria.  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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBO therapy or HBOT).

You asked the Plan to pre-approve HBO therapy. You say that you are not a candidate for bypass and have a possibility of losing your leg. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not have a covered indication for HBO therapy.

The Plan follows Medicare rules. Medicare rules state that HBO therapy may be covered for certain specific indications. 

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 HBO therapy. Our reviewer says that you do not meet the Medicare criteria for HBO therapy. Our physician reviewer found the record indicates that you have a lower extremity ulcer due to chronic arterial insufficiency. This is not an indication for which coverage is available. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBO therapy or HBOT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five localized deliveries of antimicrobial agents (D4381 x5).

You asked the Plan to pre-approve the localized deliveries of antimicrobial agents. The Plan denied your request. The Plan says this 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 five localized deliveries of antimicrobial agents (D4381 x5).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99053 billed for date of service May 22, 2021.

You asked the Plan to pay for procedure code 99053. You say that you submitted medical records to support payment of this code. The Plan denied your request. The Plan says separate payment is not allowed for this code.

The Plan must follow Medicare rules. Medicare rules say that payment for services with a status indicator of 'B' is bundled into payment for other services rendered. Separate payment is not available for these services. Procedure code 99053 has a status indicator of 'B'. We looked at the file and Medicare rules. Therefore, we decided that the Plan does not have to pay for procedure code 99053 billed for date of service May 22, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Venofer.

You asked the Plan to pre-approve Venofer. You say that this drug is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says that the labaoratory values necessary have not been provided.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 pre-approve Venofer. Our reviewer says that the requested drug is medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the record indicates that the enrollee has a diagnosis of anemia in the setting of renal transplant complications with chronic kidney disease and a glomerular filtration rate of 17. The record indicates that the enrollee is iron deficient and receiving erythropoietin. The Food and Drug Administration has stated that the requested drug is indicated for the enrollee's condition. The requested medication is being prescribed for a medically accepted indication as defined by Medicare rules. The elements of the coverage criteria are satisfied. The requested service is recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Venofer have been met. Therefore, we decided that the Plan has to pre-approve Venofer.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lenses (V2781), addition to lens; tint, any color, solid, gradient or equal, excludes photochromatic, any lens material (V2745), and frames (V2020) provided April 14, 2021.

You asked the Plan to pay for the lenses with tint and frames. You say that you need new glasses every year. The Plan denied your request. The Plan says you have exhausted your eyewear benefit.

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 standard lenses and frames once every two years. 

We looked at the file and the Plan's rules. In this case the Plan provided documentation showing that standard lenses and frames were previously covered on August 11, 2020. Based on this information, we decided that the Plan's routine vision benefit for standard frames and lenses has been exhausted. Though the Plan offers vision benefits in excess of Medicare coverage, the additional tinting on the lenses is not a covered service. Therefore, we decided that the Plan does not have to pay for the progressive lenses (V2781), addition to lens; tint, any color, solid, gradient or equal, excludes photochromatic, any lens material (V2745), and frames (V2020) provided April 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve basic routine supplies (A0382), ground mileage (A0425), and non-emergency ambulance transportation (A0428) to be rendered by an out-of-network (OON) provider.  

You asked the Plan to pre-approve the basic routine supplies, ground mileage, and non-emergency ambulance transportation. You say that the enrollee has been transported by this same OON provider for years and does not wish to switch ambulance providers. You also say that the enrollee needs ambulance transportation for all of his medical appointments. The Plan denied your request. The Plan says the records do not indicate that the enrollee has an emergent or urgent medical condition or is in need of specialized services that are not available in the Plan's network. The Plan also says that there are in-network providers within a reasonable distance from the enrollee's location that can provide this service or item.  

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve basic routine supplies (A0382), ground mileage (A0425), and non-emergency ambulance transportation (A0428) to be rendered by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an interspinous stabilization device.  

You asked the Plan to pre-approve the requested services. You say that it is very difficult to maintain an active lifestyle. The Plan denied your request. The Plan says the device has not been proven to be medically effective.  

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 requested services. Our physician reviewer found that in this case, you have severe central canal stenosis at L2-L3 and L4-L4. The interspinous spacer may be implanted at one or two adjacent lumbar levels when operative treatment is indicated at no more than two levels, from L1 to L5. Therefore, the elements of the coverage criteria are not satisfied.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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 you appear to be unstable at this time and require additional short-term additional acute care services to further stabilize that can be safely administered at the current facility for the time being. There are no services at the LTACH that you require that are not already available at the current facility.  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.