Persius/hicric huggingface dataset:
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 portable ventilator. You say that your current oxygen tank is very bulky and not able to be easily transported. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because a ventilator is not covered for the requested use and your needs can be met by a bi-level positive airway pressure (BiPAP) with average volume assured pressure support (AVAPS) mode.  The Plan must follow Medicare rules. Medicare rules say that a ventilator used to provide positive airway pressure (PAP) therapy is not covered by Medicare, regardless of the illness treated by the device.   We looked at the file and Medicare rules. The requested use of a ventilator is not covered by Medicare. The Plan has state that they would consider approval of a bi-level positive airway pressure device (E0471) upon request. Please contact the Plan regarding your treatment options. Based on this information, we decided that Medicare rules for coverage of portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on May 19, 2021.  You asked the Plan to pay for the GeneSight Psychotropic 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 missing required information.  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 81479 is not supported in the medical record. Specifically, the documentation shows that the required DEX-Z code was not entered on the claim. Based on this information, we decided that Medicare rules for coverage of the GeneSight Psychotropic testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing rendered on May 27, 2021.  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 procedure code G0483 is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code G0483 is definitive drug testing, 22 or more drug classes.  We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation of testing of 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an oral device to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an oral device. You say that this device is medically necessary. The Plan denied your request. The Plan says there are in-network providers available to provide this oral device.  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 an oral device to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray services coded 73620 provided on July 26, 2021.  You asked the Plan to pay for the x-ray services. 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 separately payable.  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 73620 for the x-ray services is a column II code to column I code 73630. 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 the x-ray services coded 73620 provided on July 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the inpatient hospital care provided from September 23, 2020, to September 29, 2020.  You asked the Plan to pay an additional amount for the inpatient care. You say that the provided documentation supports the secondary diagnosis of E43. The Plan denied your request. The Plan says the billing of secondary diagnosis code, E43, is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.  In this case, you billed the inpatient services provided with secondary diagnosis, E43, defined as unspecified, severe protein calorie malnutrition. 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 an additional amount for the inpatient care. Our reviewer says that the billing of secondary diagnosis code, E43, is not supported. Our physician reviewer found while severe protein calorie malnutrition was included in provider documentation, other documentation was unclear and incomplete regarding this condition. The reviewer found that progress note documentation from the attending and vascular consultant recorded physical exam findings of well-developed and well-nourished. Review of the medical record available was incomplete to reflect significant weight loss, low body mass index, severe muscle mass loss or reduction of food intake for greater than 1 week or provider documentation addressing the significance of nutrition consult recommendations to substantiate a condition of severe malnutrition. Additionally, provider documentation addressing the significance of nutrition recommendations was not located in the records received. Therefore, the reviewer has determined that the documentation did not support the billing of secondary diagnosis code, E43, unspecified, severe protein calorie malnutrition.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay an additional amount for the inpatient hospital care provided from September 23, 2020, to September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an out-of-network referral for an audiology visit.  You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are audiology providers available in the network.  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 an out-of-network referral for an audiology visit.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for the subsequent nursing facility care (99308) provided on July 8, 2021.  You asked the Plan to pay for the subsequent nursing facility care. You say that this service was rendered due to medical necessity and patient care was provided as an urgent request to avoid wound complications. The Plan denied your request. The Plan says that the out-of-network provider did not get health plan approval for these services. The Plan also says there was no written referral and there are in-network providers available.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan says that the treating provider is out-of-network and authorization was not obtained for the service. The 2021 Evidence of coverage states that neither a referral nor prior authorization is necessary when getting care from out-of-network providers. There was no valid reason or evidence that supported the Plan's denial for no authorization being obtained. Therefore, we decided that the Plan has to pay for the subsequent nursing facility care (99308) provided on July 8, 2021.   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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance mileage rendered on March 4, 2021.  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 a status indicator of I represents a code that is not valid for Medicare purposes.   We looked at the file and Medicare rules. Billed procedure code A0380 (basic life support mileage, per mile) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the ambulance mileage rendered on March 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Eligard syringe kit.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.  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 Eligard syringe kit.   Benefits for these services 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve infusion services to be provided at the in-network benefit level by an out-of-network (OON) provider.  You asked the Plan to pre-approve infusion services. You say that you are the only home infusion provider in the area and there is no way the enrollee can use an in-network provider for home infusion. The Plan denied your request. The Plan says the denial of authorization for coverage at the in-network benefit level is correct, because this provider is out-of-network with the Plan and the enrollee can receive service from an in-network infusion provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that enrollees may choose to receive care from an out-of-network provider that is eligible to participate in Medicare, but the share of costs for covered services may be higher.  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 at the in-network benefit level. Therefore, we decided that the Plan does not have to pre-approve infusion services to be provided at the in-network benefit level by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 12, 2021.

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 not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is considered experimental/investigational.

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 Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is not supported by two Orthopedic societies. The procedure is still considered experimental/investigational. 

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a radiofrequency ablation of the lumbar spine (64635, 64636) provided on June 22, 2021.  You asked the Plan to pay for a radiofrequency ablation of the lumbar spine. You say that the procedure at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the procedure at issue have not been met.  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 a radiofrequency ablation of the lumbar spine. Our reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found that there was no documentation provided regarding any diagnostic injections of the lumbar spine. The enrollee does not meet Medicare coverage criteria for the radiofrequency ablation.  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 radiofrequency ablation of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pay for a radiofrequency ablation of the lumbar spine (64635, 64636) provided on June 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Monovisc.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the provider's office said that Monovisc will be supplied by a pharmacy.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Monovisc.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services from July 4, 2021, to July 7, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were dissatisfied with hospital stay and don't feel you should have to pay for the services. The Plan denied your request. The Plan says the copayment was applied correctly.  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 $245 copayment per day per admission for days 1-5 of an inpatient hospital stay.  You have been asked to pay a total of $735 ($245 copayment x 3 days = $735) for the inpatient hospital services. The inpatient hospital services fall within the Inpatient hospital care benefit category. 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 copayment for the inpatient hospital admission and services from July 4, 2021, to July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a prefabricated post and core (D2954) provided on May 20, 2021.

You asked the Plan to pay for a prefabricated post and core. You say that you want the Plan to reimburse you for the service. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 60 months.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a prefabricated post and core have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on December 2, 2019. Therefore, we decided that the Plan does not have to pay for a prefabricated post and core (D2954) provided on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the porcelain fused to predominantly base metal crown (D2751) for tooth #28.  You asked the Plan to pre-approve the crown. You say that you need this service to be reconsidered because you really need the crown. The Plan denied your request. The Plan says this service exceeds the benefit allowance. 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, porcelain/stainless steel crowns are limited to once per 60 months per tooth. The record shows that you received a porcelain fused to predominantly base metal crown (D2751) on tooth #28 on November 3, 2020 and your crown benefit for tooth #28 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve the porcelain fused to predominantly base metal crown (D2751) for tooth #28.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) and the laboratory service (80305) rendered by the out-of-network (OON) provider on June 22, 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 office visit (99214) and the laboratory service (80305) rendered by the out-of-network (OON) provider on June 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Voriconazole for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under 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 Voriconazole for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.