Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for critical care services provided to the enrollee from August 14, 2021, to August 15, 2021.  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 Current Procedural Terminology (CPT) code 99291 (1 unit) remains 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 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes."  We find that CPT code 99291 is not supported in the medical record. Specifically, there was no documentation showing the time spent providing the critical care services. This documentation is necessary as CPT 99291 is a time-based code. 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 critical care services provided to the enrollee from August 14, 2021, to August 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve alveoloplasty not in conjunction with extractions (D7320) and removal of torus mandibularis (D7473).  You asked the Plan to pre-approve the dental services. You say that these services are necessary, and you will not be able to afford them on your own. The Plan denied your request. The Plan says these services are not covered by your dental 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 alveoloplasty not in conjunction with extractions (D7320) and removal of torus mandibularis (D7473).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Digoxin tablet.  You asked the Plan to pre-approve Digoxin. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not 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 Digoxin tablet.   Benefits for Digoxin 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a lumbar-sacral orthosis provided on March 4, 2020  You asked the Plan to waive the coinsurance for a lumbar-sacral orthosis. You say that you disagree with the charges because you never received the device. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  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 20% coinsurance for prosthetic devices and related supplies.   The medical records show that you received a lumbar-sacral orthosis on March 4, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $1,371.22 and 20% of that is $274.24.   You have been asked to pay the total coinsurance amount of $274.24 for a lumbar-sacral orthosis. A lumbar-sacral orthosis falls within the prosthetic devices and related supplies 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 coinsurance for a lumbar-sacral orthosis provided on March 4, 2020
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergent ambulance services (A0428 and A0425) provided on July 12, 2021.  You asked the Plan to pay for the non-emergent ambulance services. You say that you would like reconsideration because the ambulance services were medically necessary. The Plan denied your request. The Plan says the member was registered inpatient on the billed date of service.  The Plan must follow Medicare rules. Medicare rules say that transportation, including transportation by ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where the patient is an inpatient is covered by the prospective payment rate.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance services have not been met. Specifically, the record indicates that the member was registered inpatient on the billed date of service. Payment for the ambulance services is included in the payment to the facility for the inpatient services. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance services (A0428 and A0425) provided on July 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services provided from July 21, 2021, to August 21, 2021.  You asked the Plan to waive the copayment for the SNF services. You say that you cannot afford this bill. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  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 $0 per day for days 1-20 and $167 per day for days 21-100 for each skilled nursing facility (SNF) benefit period.     Service Dates Copayment Total Skilled Nursing Facility July 21, 2021 - August 9, 2021 $0 per day $0 Skilled Nursing Facility August 10, 2021 - August 19, 2021 $167 per day $1670 Skilled Nursing Facility August 20, 2021 $167 per day $3.97 Total:   $1673.97  The record shows that you were in a skilled nursing facility from July 21, 2021, to August 21, 2021. You have been asked to pay $1673.97 for days 21-32 for the SNF services. Please note that your maximum out-of-pocket expenses had been met on August 19, 2021, reflected by the reduced copayment amount. There is also no charge for the discharge date. The SNF services fall within the Skilled Nursing Facility (SNF) 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 skilled nursing facility (SNF) services provided from July 21, 2021, to August 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acupuncture, initial 15 minutes (98710) acupuncture, each additional 15 minutes (98711) provided June 16, 2021.  You asked the Plan to pay for the acupuncture services. You say that kindly reprocess the claims and release the payment at the earliest. The Plan denied your request. The Plan says this is a non-covered provider type.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the services were rendered by a licensed acupuncturist, not a physician. This provider is not supervised by a physician, PA, or NP/CNS. Therefore, we decided that the Plan does not have to pay for the acupuncture, initial 15 minutes (98710) acupuncture, each additional 15 minutes (98711) provided June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for eyeglass lenses provided on July 23, 2021.  You asked the Plan to reimburse you for eyeglass lenses. The Plan denied your request. The Plan says you must use the Plan's vision network provider for coverage of routine eyewear.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the eyeglass lenses were not provided by the Plan's vision network provider.  Based on this information, we decided that the Plan's rules for coverage of eyeglass lenses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglass lenses provided on July 23, 2021.
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 the enrollee is presently receiving these services in the short-term acute care setting. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as a sub-acute rehabilitation facility or a skilled nursing 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.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the insertion of gastrostomy tube (49440) provided on September 10, 2021.  You asked the Plan to pay for the insertion of gastrostomy tube (49440). You say that this was denied for place of service, but the procedure was rendered in the appropriate place of service. You say that the claim should be reviewed and reconsidered for payment. The Plan denied your request. The Plan says the claim was billed with an inappropriate place of service 22 (outpatient) while the member was an inpatient.  The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule, the Place of service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face-to-face service.     We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of gastrostomy tube (49440) have not been met. Specifically, the enrollee was an inpatient at the time of service. The claim was billed with POS code 22 (on campus outpatient hospital) instead of POS code 21 (inpatient hospital). Therefore, we decided that the Plan does not have to pay for the insertion of gastrostomy tube (49440) provided on September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services (97110) provided on January 27, 2021.  You asked the Plan to pay for physical therapy services. You say that this should be covered. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that coverage of services incident to the professional services of a physician or non-physician practitioner (NPP) is limited to situations in which there is direct supervision of auxiliary personnel.   We looked at the file and Medicare rules. The record does not show that the billing practitioner was present for direct supervision. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97110) provided on January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313).  You asked the Plan to pre-approve an expandable controller. You say that this is medically necessary. The Plan denied your request. The Plan says the power options can be operated with their own switches.  The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered only when medically necessary for a function detailed in the 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 an expandable controller. Our reviewer says that the requested expandable controller is not medically necessary. Our physician reviewer found the patient does not require a separate display, other electronic devices, or an attendant control. The patient has only 2 power options and his upper extremity strength and function support that the patient can control any power options through their own switches.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 2, 2021.  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 the records do 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 find that procedure code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 9, 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 codes 80157, 80177, 80201, 80162, 80159, and 80173 are 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.  We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, the records do not document the specimen type collected for testing. 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 laboratory services rendered on March 9, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Gel-One (J7326).  You asked the Plan to pre-approve Gel-One. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested treatment have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Gel-One. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that step therapy criteria have not been met because a first-line med such as Orthovisc or Monovisc must be trialed first.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Gel-One (J7326).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter (power operated vehicle, item code K0800).  You asked the Plan to pre-approve power scooter. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee is not significantly impaired in mobility-related activities of daily living (MRADLs) in the home and the mobility limitation can be sufficiently and safely resolved using a 4-wheeled walker with a seat.  The Plan follows Medicare rules. Medicare rules state that a power operated vehicle (POV), such as a power scooter, may be covered if certain criteria are met.  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 power scooter. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested power scooter. Our physician reviewer found the documentation does not support that the enrollee has a mobility deficit that impairs mobility-related activities of daily living MRADLs) in the home and that this mobility limitation is not ameliorated by a walker. While the enrollee may have the cognition to safely operate the power scooter, the documentation does not reveal a detailed in-person home assessment with objective measurements to support that the requested device will be able to safely maneuver in the home and access rooms for MRADL participation. The documentation does not show that a power scooter is 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 power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter (power operated vehicle, item code K0800).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.  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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an oxygen (O2) concentrator and portable oxygen (O2) system.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a need for oxygen.  The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.    To qualify for home oxygen, the patient must meet one of the following blood gas levels:  1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;  2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;   3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;  4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.  For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.  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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found home supplemental oxygen is deemed not medically necessary. You have asthma and/or chronic obstructive pulmonary disease (COPD), and were hospitalized for an exacerbation in November 2021. You were discharge on oxygen at 2 Lpm during exercise. The records do not show a room air oxygen saturation less than 89%, and there is no oximetry testing during activity or during sleep.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen (O2) concentrator and portable oxygen (O2) system.