Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on
March 25, 2021.
You asked the Plan to pay an additional amount for the eyeglasses. You say that you were quoted a price for progressive lenses as covered under the Plan vision benefit. The Plan denied your request. The Plan says the claim processed and paid correctly.
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 Plan processed and paid the claim with the maximum eyewear benefit allowance of $200. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on March 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from May 8, 2020, to May 31, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid as it was submitted correctly. The Plan denied your request. The Plan says the medical records provided 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 codes. 

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 these services. Our reviewer says that Medicare billing criteria are not met. Our reviewer found at issue is whether the documentation provided supports the billing of KDBD1 for 24 days.

The enrollee is a 77-year-old woman who was hospitalized from March 30, 2020 to May 8, 2020. The enrollee has acute-on-chronic respiratory failure. A tracheostomy has been placed. The SLP documentation in the case file is limited to the Summary of Daily Skilled Services dated May 11, 2020. "Physician's order received, chart reviewed, history noted, evaluation completed, and Plan of Treatment developed on this date, and initiated instruction/training in reason for skilled ST evaluation. SLP educated pt. on assessment results and 1X evaluation post assessment.; 92610: Physician's order received, chart reviewed, history noted, evaluation completed, and Plan of Treatment developed on this date, and initiated instruction/training in current diet recommendations and s/s of aspiration. SLP educated on s/s in order to increase pt. awareness of aspects to caution for during the swallow." Based on the records provided, the documentation is insufficient to demonstrate that reimbursement under the SLP Case Mix Group SD is warranted. The documentation is insufficient to support the coding of Tracheostomy Care performed by support staff or the member during the reference period in question. Medicare billing criteria are not met. 

We looked at this coder's review, the file, and Medicare rules. 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 skilled nursing facility services provided to the enrollee from May 8, 2020, to May 31, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for an introduction of a needle or catheter procedure (36902) and a transluminal balloon angioplasty (36907) with moderate sedation services (991152, 99153) provided on February 11, 2021, by an out-of-network provider.

You asked the Plan to pay for an introduction of a needle or catheter procedure and a transluminal balloon angioplasty with moderate sedation services. You say that the services at issue were emergency care. The Plan denied your request. The Plan says that rules for out-of-network care have not been met because the services at issue were non-emergent and were not pre-approved.

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 at issue in this case is not a network provider with the Plan. 

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 an introduction of a needle or catheter procedure and a transluminal balloon angioplasty with moderate sedation services. Our reviewer says that the procedures at issue were both emergent and necessary. Our physician reviewer found that the services at issue were emergent life-sustaining procedures that were medically reasonable and necessary. If the procedures were not done emergently, there would be risk for mortality and hospitalization for the enrollee. 

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 introduction of a needle or catheter procedure and a transluminal balloon angioplasty with moderate sedation services have been met. Therefore, we decided that the Plan has to pay for an introduction of a needle or catheter procedure (36902) and a transluminal balloon angioplasty (36907) with moderate sedation services (991152, 99153) provided on February 11, 2021, by an out-of-network provider.

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 pay for orthoses (L1851, L2397, L0648) provided March 24, 2021.

You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied your request. The Plan says the items were provided following an unsolicited telehealth consult. Coverage rules have not been met.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for orthoses (L1851, L2397, L0648) provided March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services (38500) provided April 22, 2021.
You asked the Plan to pay for the surgical assistant services. You say that the surgical assistant services were medically necessary. The Plan denied your request. The Plan says surgical assistants are not covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 38500. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid.
Based upon this information, we find that Medicare coverage criteria for the surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services (38500) provided April 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (99214) provided October 27, 2020.

You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says the provider is not eligible for Medicare payment as they have opted out of the program.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (99214) provided October 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on April 26, 2021. 
 
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says the physical 
therapy is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the service did not address balance training and vestibular 
rehabilitation as ordered by the prescribing physician. Our reviewer says that the unique skills of a professional 
therapist were not required to safely and effectively provide treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pay for physical therapy provided on April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the intravitreal injection of a pharmacologic agent (67028), ophthalmological medical examination and evaluation (92014), and the scanning computerized ophthalmic diagnostic imaging (92134) provided on May 24, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 $275 copayment for Medicare-covered outpatient hospital and observation services.
You have been asked to pay a $275 copayment for the Medicare-covered outpatient hospital services provided. 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 intravitreal injection of a pharmacologic agent (67028), ophthalmological medical examination and evaluation (92014), and the scanning computerized ophthalmic diagnostic imaging (92134) provided on May 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs (A9270) provided during a hospital stay on April 21, 2021 to April 23, 2021.
You asked the Plan to pay for the self-administered drugs. You say that the drugs should be covered as the hospital stay was medically necessary. The Plan denied your request. The Plan says self-administered drugs are not eligible for coverage under the Part B 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 pay for self-administered drugs (A9270) provided during a hospital stay on April 21, 2021 to April 23, 2021.
Benefits for the self-administered drugs 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services provided on March 23, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
are not a Medicare covered service. 
 
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 the services provided. Our physician 
reviewer found that the enrollee has diabetic neuropathy of her lower extremities. She had TENS treatments, 
pneumatic compression and vitamin injections. These services are experimental investigational and do not meet 
requirements. Therefore, the procedures were not medically reasonable or necessary to treat the enrollee. 
 
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 provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the pain management services provided on March 23, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the rotary wing air transport (A0431) and rotary wing air mileage (A0436) provided on January 14, 2021.

You asked the Plan to pay for the air ambulance services. You say that this was an emergent situation which should not have required a prior authorization. You say that the enrollee required cardiac monitoring. You also say that the air ambulance reached its destination 3 times faster than a ground ambulance would have. The Plan denied your request. The Plan says that the enrollee could have been safely transported by another type of motor vehicle, possibly a van transport vehicle.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the air ambulance services. Our reviewer says that the air ambulance services are medically necessary. Our physician reviewer found the record indicates that the enrollee was seen at the doctor's office for chest pain and had ST segment elevation. The reviewer found that the physician directed the enrollee to the emergency room. The enrollee went home to call the ambulance. The record indicates that at the time of arrival, monitor showed atrial tachycardia with anterior ST segment elevation concerning for acute myocardial ischemia. The reviewer found that the transportation time via air was 19 minutes to the nearest regional specialty center 44 miles away. The enrollee required immediate care that the distance precluded ground transportation.

Therefore, the reviewer found that the elements of the coverage criteria are 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 air ambulance services have been met. Specifically, the file indicates that the enrollee required immediate care that the distance precluded ground transportation. Therefore, we decided that the Plan has to pay for the rotary wing air transport (A0431) and rotary wing air mileage (A0436) provided on January 14, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on April 8, 2020.
You asked the Plan to pay for anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy (00790). You say that the original claim was filed timely. The Plan denied your request. The Plan says the corrected claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy (00790) was not filed until May 12, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on April 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to an inpatient mental health facility after September 8, 2021.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's condition has improved, and is no longer a threat to themselves and others.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 based upon a review of the records provided for the admission, this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of August 24, 2021 forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations, and was cooperative/compliant with treatment. The enrollee was not showing any aggressive behaviors, or any treatment required for acute threats to safety. The health plan's denial of continued inpatient psychiatric services is appropriate. 

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 continued admission to an inpatient mental health facility after September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for headgear for a positive airway device (A7035) provided
February 8, 2021.
You asked the Plan to pay for the headgear. You say that the item was medically necessary. The Plan denied
your request. The Plan says the amount of this item provided exceeds the amount allowed under Medicare
coverage rules.
The Plan must follow Medicare rules. Medicare rules say that quantities of supplies greater than those
described in the policy as the usual maximum amounts will be denied as not reasonable and necessary
We looked at the file and Medicare rules. Medicare rules state that 1 of this accessory is covered every six
months. The record shows that this type of accessory was already provided within the 6 months prior. Based on
this information, we decided that Medicare rules for coverage of the headgear have not been met. Therefore, we
decided that the Plan does not have to pay for headgear for a positive airway device (A7035) provided
February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiofrequency ablation services provided on April 5, 2021.
You asked the Plan to pay for the services provided. You say that the documentation supports the services provided. The Plan denied your request. The Plan says the clinical effectiveness has not been demonstrated.
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 the services provided. Our physician reviewer found that the enrollee has sacroiliitis. She takes Norco, Baclofen and Voltaren gel for pain. She had radiofrequency ablation (RFA) of the lateral sacral nerves in 2019 with 75% pain relief, and then again in 2020 with 100% pain relief for several months. RFA of the lateral sacral branches is considered experimental/ investigational due to the wide variation in efficacy reported in the literature. Therefore, the request is deemed not medically reasonable or 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 services provided have not been met. Therefore, we decided that the Plan
does not have to pay for the radiofrequency ablation services provided on April 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits.

You asked the Plan to pre-approve home health care. You say that you are appealing with supporting records.
The Plan denied your request. The Plan says the denial of authorization for additional home health care is
correct.

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 home health care. Our reviewer says
that you do not meet the Medicare criteria for this home health care. Our physician reviewer found the
documentation does not support that you require additional skilled nursing services to provide treatment that is
medically necessary. You do not require additional skilled nursing services to effectively provide treatment,
care, and/or services in order to improve your condition, perform a maintenance program to maintain your
condition, and/or prevent deterioration. You have been medically stable without any recent exacerbations of
chronic medical problems or hospitalizations.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does
not have to pre-approve home health skilled nursing visits.