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

 We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on May 6, 2021.  You asked the Plan to pay for the ground mileage and non-emergency ambulance transportation. You say that this transport was both reasonable and medically necessary. The Plan denied your request. The Plan says the criteria for non-emergency ambulance transportation have not been met.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ground mileage and non-emergency ambulance transportation. Our reviewer says that there is no documentation that the ambulance transport on May 6, 2021 met Medicare criteria for medically reasonable and necessary for the patient. Our physician reviewer found there is no documentation that a stretcher van or wheelchair van was contraindicated for this patient on this date of service. The records do not document the patient was unable to sit in a chair or wheelchair. Our reviewer also found that there is no documentation that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on May 6, 2021.  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 ground mileage and non-emergency ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #30.  You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says tooth # 30 does not show large decay requiring replacing a significant amount of the tooth. The Plan also says that the x-rays show little decay, which can be restored with a conventional filling, and this condition does not meet the required clinical criteria to establish medical necessity.  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 the crown when the services are medically necessary and reasonable.     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 crown. Our reviewer says that the Plan's criteria requiring four or more surfaces and damaged cusps has not been met. Our physician reviewer found tooth #30 is seen on the provided x-rays with an existing one surface restoration with no carious lesions seen. The tooth has approximately 90% of the structure sill intact. Our reviewer found that the tooth appears to be readily restored, if needed, with conventional restorative materials. Crowns are commonly reserved for situations where a tooth is severely damaged and requires the strength of a full coverage restoration. Our physician reviewer also found that there does not appear to be any clear reason the tooth would need a full coverage restoration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #30.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on April 6, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on April 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lipectomy  You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation that weight has remained stable since August 2021.  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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee is still in the process of losing weight and has not reached a stable weight for a period of six months. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve lipectomy
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that you need inpatient rehabilitation to return to your prior level of independence. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in an alternate setting.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (92136) provided on July 12, 2021.  You asked the Plan to waive the copayment for ophthalmic biometry. The Plan denied your request. The Plan says since the allowable amount for the service is less than the $35.00 copayment, you are being asked to pay the lesser amount of $30.09. This service is not included in the global payment for the surgery.  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 $35 copayment for Vision Care, Medicare-covered vision care.   You have been asked to pay less than the $35 copayment for ophthalmic biometry. Ophthalmic biometry falls within the Vision Care, Medicare-covered vision 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 ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (92136) provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on June 21, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on June 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional home health aide hours.  You asked the Plan to pre-approve the additional hours. You say that this is medically necessary. The Plan denied your request. The Plan says there is no skilled need for an increase in hours, based on the assessment.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional hours. Our reviewer says that the requested additional hours are not medically reasonable or necessary. Our physician reviewer found the enrollee is receiving home health skilled nursing services. Associated home health aide services. are medically necessary and reasonable to establish a maintenance program and/or prevent deterioration in the enrollee's condition. The documentation, however, does not show why two three-hour blocks of home health aide care are needed per day. The enrollee has family and is able to at least partially assist in her care. These services are meant to be intermittent. As such, the requested forty-two hours per week is not medically necessary, reasonable or coverable.  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 additional hours have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health aide hours.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve OneTouch Ultra test strips.  You asked the Plan to pre-approve OneTouch Ultra test strips. You say that you would like the plan to reconsider their decision. The Plan denied your request. The Plan says the requested items are not valid for tier exceptions.  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.   In this case, you have requested OneTouch test strips to be provided at a tier exception (at a lower cost level). Tier exceptions are only available for Part D drugs. OneTouch test strips or diabetic supplies are not considered a Part D drug. Based on this information, we decided that Medicare rules for coverage of OneTouch Ultra test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve OneTouch Ultra test strips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88305) rendered by the out-of-network (OON) provider on May 14, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (88305) rendered by the out-of-network (OON) provider on May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 20, 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 office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for levocarnitine, per 1GM injection (CPT code J1955), thiamine HCL 100MG injection (J3411 (4 units)), pyridoxine HCL 100MG injection (J3415 (4 units)), unclassified drugs (J3490-KD (35 units)) provided to the enrollee on November 19, 2020.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are 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 services. Our reviewer found the review has determined that Healthcare Common Procedure Coding System (HCPCS) code J3411 (4 units) remains not supported. This service represents injection, thiamine HCl, 100 mg. The documentation submitted indicates nutria-pharmaceutical blend injection was performed; There is a more appropriate HCPCS J3490 code that should be used to bill for the service provided therefore, the billed service cannot be verified. HCPCS code J3415 (4 units) remains not supported. This service represents injection, pyridoxine HCl, 100 mg. The documentation submitted indicates nutria-pharmaceutical blend injection was performed; There is a more appropriate HCPCS J3490 code that should be used to bill for the service provided therefore, the billed service cannot be verified. HCPCS code J3490-KD (8 units) remains not supported. The documentation submitted do not support the units billed. Only one unit is appropriate to bill for this code. In addition, the documentation indicates that Bupivacaine Hydrochloride was administered in compounded form through an implantable pump and reservoir. There is a more appropriate HCPCS code, J7999, that should be used to bill for drugs that are administered in compound form. HCPCS code J1955 - 59 (1 unit) remains not supported. This service represents injection, levocarnitine, per 1 g. The documentation submitted indicate nutria-pharmaceutical blend injection was performed; There is a more appropriate HCPCS J3490 code that should be used to bill for the service provided therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. The review has determined that the services were not supported by the medical records provided.  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 levocarnitine, per 1GM injection (CPT code J1955), thiamine HCL 100MG injection (J3411 (4 units)), pyridoxine HCL 100MG injection (J3415 (4 units)), unclassified drugs (J3490-KD (35 units)) provided to the enrollee on November 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for CT, head or brain; without contrast material (CPT code 70450), for the enrollee.  You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70450 and 70496. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for CT, head or brain; without contrast material (CPT code 70450), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health physical therapy services.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee has already been educated on a home exercise program.   The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that there is no documentation that further skilled therapy services beyond what has already been approved are required to effectively provide treatment to improve the enrollee's level of function, or to perform a maintenance program to maintain her level of function or prevent deterioration. She is walking 100 feet with a rolling walker with standby assistance and was at a standby assist for transfers, which are improvements compared to her levels in July. The proposed treatment plan appears to be primarily focused on strengthening and increasing endurance, which should be achievable with a home exercise program. Therefore, the requested services are not medically necessary.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy services.
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 these services are medically necessary. The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and are currently unstable for transfer to an LTACH.  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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the coronary artery disease testing provided on July 16, 2020.  You asked the Plan to pay for the coronary artery disease testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications.  While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the coronary artery disease testing provided on July 16, 2020.