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

 We decided that the Plan does not have to pay for the emergency ambulance transportation services (A0427, A0425) provided on May 5, 2021.  You asked the Plan to pay for the emergency ambulance transportation. You say that these services were necessary and should be covered. The Plan denied your request. The Plan says the ambulance transportation was not medically necessary on the date in question. You were medically stable, did not require the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide, and there is no documentation that other forms of transportation were contraindicated.  Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.   We looked at the file and Medicare rules. Medical records indicate that you were experiencing difficulty breathing due to a runny nose. You told paramedics that you were watching the news when your nose started draining and you experienced difficulty breathing out of it. You indicated that this has happened the past couple of mornings but then goes away throughout the day. There is no indication that there was difficulty breathing for any other reason or any other urgent symptoms. Based on this information, we decided that Medicare rules for coverage of the emergency ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the emergency ambulance transportation services (A0427, A0425) provided on May 5, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you cannot walk a few steps or do basic living activities so need the SNF. The Plan denied your request. The Plan says that the denial of authorization for SNF care is correct.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that you meet the Medicare criteria for SNF care. Our physician reviewer found you do not have documented skilled nursing needs. However, you do have documented skilled therapy needs. You are not yet shown to have reached a plateau in function. You would benefit from strength training, compensatory strategy training, caregiver training, and durable medical equipment evaluations. A period of daily skilled services is needed to establish a maintenance program and/or prevent deterioration of your condition.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Retacrit (Q5106).  You asked the Plan to pre-approve Retacrit. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says the requested drug is not being prescribed for a medically-accepted indication.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Retacrit. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 77-year-old with anemia of chronic disease and iron deficiency anemia. In this case, the requested use of Retacrit is not FDA-approved for the enrollee's condition as no labs were provided to evaluate appropriateness of the requested drug. Without these labs, the request for Retacrit cannot be evaluated for medical necessity based on FDA-approval or off-label recommendations.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit (Q5106).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Butalbital-Aspirin-Caffeine capsule.  

You asked the Plan to pre-approve Butalbital-Aspirin-Caffeine capsule. You say that the drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not among those covered under the enrollee's medical benefit.  

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Butalbital-Aspirin-Caffeine capsule.   

Benefits for Butalbital-Aspirin-Caffeine capsule 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating provider on July 27, 2021.  

You asked the Plan to pay for a limited oral evaluation. You say that you had unbearable pain and needed this evaluation. The Plan denied your request. The Plan says the benefit limit for a limited oral evaluation 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. The Plan covers a limited oral once per calendar year.  

We looked at the file and Medicare rules. Evidence was provided to show that a limited oral evaluation was provided on July 15, 2021. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have already been exhausted. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating provider on July 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the duplex scans (93978, 93880) and office visit with a specialist (99213) provided on May 25, 2021.  You asked the Plan to waive the copayment for the diagnostic imaging services and office visit. You say that you are being charged a second copayment and feel this is incorrect as you only saw the one provider on the date in question. The Plan denied your request. The Plan says the Plan has agreed to waive the copayments for the second provider; however, you are still responsible for a copayment for diagnostic tests and a copayment for the office visit with a specialist.  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 $30 copayment for an office visit with a specialist and a $30 copayment for diagnostic procedures and tests provided by a specialist.   You have been asked to pay a $30 copayment for the diagnostic procedures and a $30 copayment office visit provided by a specialist. 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 duplex scans (93978, 93880) and office visit with a specialist (99213) provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for needle electromyography (procedure code 95870) provided to the enrollee on August 28, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was not billed with an allowed modifier.  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 95870 is "Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters."  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 services at issue in this case were not supported by the medical records. Our reviewer found the documentation submitted was reviewed, and does not meet the criteria. CPT 95868 was also reported and approved for payment, however, CPT 95870 is inclusive to CPT 95868, unless an appropriate modifier (-59) is appended and supported as a distinct procedural service. In this case, modifier 26 was reported, and therefore this service would not be covered.   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 needle electromyography (procedure code 95870) provided to the enrollee on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate (CPT code 99497) provided to the enrollee on February 22, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records. 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 service. Our reviewer found documentation submitted was reviewed and does not meet criteria. Documentation includes a hospital visit dated February 21, 2021, at 11:27 AM. No documentation was included to support a visit with advance care planning explanation and discussion. Therefore, CPT 99497 for date of service February 22, 2021, cannot be verified as performed.  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 service have not been met. Therefore, we decided that the Plan does not have to pay for advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate (CPT code 99497) provided to the enrollee on February 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve continued chiropractic services.  You asked the Plan to pre-approve the chiropractic services. You say that the chiropractic treatment is helping with your pain and you would like to continue the services. The Plan denied your request. The Plan says that the enrollee does not meet the coverage criteria to qualify for continued chiropractic care.   The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation when there is an expectation of improvement in function.    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 chiropractic services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation supports that the services provided were to correct a subluxation. The documentation supports that continued chiropractic services are medically reasonable and necessary for the enrollee in this case. The enrollee indicated increased pain in the S.I. joint. The chart notes dated 11/1/21, 11/3/21, and 11/8/21 document subluxations at the L4, L5, and sacral levels, demonstrated by the objective findings. It was determined that continued chiropractic care was necessary for the goal to be met.  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 chiropractic services have been met. Therefore, we decided that the Plan has to pre-approve continued chiropractic services.   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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392).  

You asked the Plan to pre-approve the portable oxygen concentrator. You say that you need this item. The Plan denied your request. The Plan says you currently have the standard item that meets your medical needs.  

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  

The file shows that you have a stationary concentrator and home fill D-tanks. The stationary concentrator and home fill D-tanks serve the same purpose as the portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from June 2, 2020 to June 9, 2020.  

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the billing of diagnosis code J15.6. 

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 principal diagnosis J15.6 (pneumonia due to other Gram-negative bacteria). 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 these services. Our reviewer says that the submitted records do not support the billing of diagnosis code J15.6. Our physician reviewer found the records document "gram negative pneumonia" but no supporting documentation was submitted. There is no provider order for sputum cultures. While a positive pathogenic organism may not always be found or a patient may not be able to produce a sufficient specimen, an order for a sputum culture would still be expected to aid in effective guideline-based management of a patient with a suspected gram-negative pneumonia. The records do not support the billing of the principal diagnosis J15.6.   

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 for the inpatient hospital services rendered from June 2, 2020 to June 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for aortography (75625) and angiography (75710) provided on June 16, 2021.  You asked the Plan to pay for the aortography and angiography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services 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 asked our physician 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 aortography and angiography. Our reviewer says that CPT code 75625 does not meet criteria for billing or reimbursement consideration. Based on the medical records provided there is no documentation that supports CPT code 75625. The operative report states: "The catheter was exchanged out for 4 French sheath. A wire was fed to aorta and a flush catheter positioned aorta. Angiography aortoiliac was obtained in multiple obliquities. The aortic bifurcation was tucked and the catheter tract to the inguinal ligament and a wire was fed into the superficial femoral artery." This description does not meet criteria for CPT code 75625 as defined by the National Correct Coding Initiative Policy Manual for Medicare Services. Our reviewer found CPT code 75710 does not meet criteria for billing or reimbursement consideration. CPT cpde 75710 is included in the payment for CPT code 37225.  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 aortography and angiography have not been met. Therefore, we decided that the Plan does not have to pay for aortography (75625) and angiography (75710) provided on June 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for home health services for the enrollee.
You asked the Plan to provide coverage for home health services. At the time of the appeal, you stated that
home health services were medically necessary. The Plan denied your request. The Plan says Medicare
coverage criteria are not met. Maximus overturned the Plans denial of a lack of notice of non-coverage. The
Plan requested a reopen and stated that this was not the denial of continuing care as it was a request for a new
episode of home health services.
The Plan is correct in this case. 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. Based
on the medical records provided, this was not continued care but a new request for home health services. Also
based on the medical records provided, at the time of the appeal, the enrollee did not meet the criteria required
for these services. Therefore, we decided that the Plan does not have to provide coverage for home health
services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT code 99239) provided to the enrollee on April 27, 2020.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  The documentation submitted does not include a hospital discharge day management note with a recorded duration of time of 31 minutes or more for the billed date of service of April 27, 2020; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT code 99239) provided to the enrollee on April 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.  

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy.  

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network ophthalmologist.  

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 the services are available from network providers.  

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 a referral to an out-of-network ophthalmologist.