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

 We decided that the Plan does not have to pre-approve non-emergent ambulance transportation.  You asked the Plan to pre-approve the non-emergent ambulance transportation. You say that the enrollee is 95 years old, bed ridden, and needs to go from the stretcher to a radiation table. You also say that the enrollee has been denied because the treating facility is not directly in the hospital building but very close to it. The Plan denied your request. The Plan says the documentation indicates that transport by wheelchair van would not endanger the enrollee's health. The Plan also says that transportation via an ambulance is not medically required.  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 pre-approve the non-emergent ambulance transportation. Our reviewer says that the non-emergent ambulance transportation is not medically necessary Our physician reviewer found the record indicates that the enrollee requested transportation to a radiation oncology office. Our reviewer found that the record indicates that the enrollee is wheelchair bound. Our reviewer also found that the patient's clinical condition is not such that other methods of transport, such as wheelchair van or stretcher van, are contraindicated.    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 non-emergent ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergent ambulance transportation.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Synvisc (J7325).  You asked the Plan to pre-approve Synvisc. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Orthovisc or Supartz FX.  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 Synvisc. Our reviewer says that Synvisc is not medically necessary. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternatives. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternatives. Therefore, the reviewer found that the step therapy criteria have not been met for the requested drug, Synvisc.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Specifically, the file does not show that the enrollee has tried and failed the plan's preferred step one alternatives. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on September 7, 2021.  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. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70496 is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services provided on August 26, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code is not paid separately.  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 99100 is Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99100 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on August 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an electronic connection (E2311) for a power wheelchair.  You asked the Plan to pre-approve an electronic connection. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for the requested item have not been met.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an electronic connection. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case.  Our physician reviewer found that the provided documentation does not reveal objective detailed physician progress notes indicating that the patient requires the item coded E2311 to control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation, power standing.  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 electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311) for a power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services received on August 26, 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 provider did not bill as required by Medicare coding regulations    The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74018 is a column II code to column I code 74019. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services received on August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cardiovascular genetic risk assessment testing (CPT code(s): 81404, 81405, 81406, 81439) provided to the enrollee on November 2, 2020.  You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular genetic risk assessment panels.  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.  The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiovascular genetic risk assessment testing (CPT code(s): 81404, 81405, 81406, 81439) provided to the enrollee on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214-25) provided on August 17, 2021.  You asked the Plan to pay for the office visit. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT code 99214-25 is not supported in the medical record. The office visit at issue was billed with modifier 25, which is used to report a significant, separately identifiable Evaluation and Management (EM) service by the same physician or other qualified health care professional on the same day of a procedure or other service. There is no documentation of any significant, separately identifiable evaluation unrelated to the treatment provided to the enrollee on this date of service. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99214-25) provided on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for molecular pharmacogenetic pathology testing provided to the enrollee on September 14, 2021.  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 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 services have not been met. As Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently satisfactorily described by any existing CPT code; to report a CGP, service providers should use 1-unit only of CPT code 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes. Coverage of CGP is limited to one test per specimen and precludes the use of any other molecular testing on the specimen. Therefore, we decided that the Plan does not have to pay for molecular pharmacogenetic pathology testing provided to the enrollee on September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the hearing aids.  You asked the Plan to pre-approve the hearing aids. You say that you've had a hearing aid for 7 years and it's time for a replacement. You say that the right one is not working, and you don't understand why it was denied. The Plan denied your request. The Plan says there is not an order or records from a physician, therefore, the request is not approved.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when supplied by a hearing aid dispenser on the prescription of an otolaryngologist, or the attending physician when no otolaryngologist is available.   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 hearing aids. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found that the records do not contain a note from a treating otolaryngologist or the attending physician attesting to the necessity of the new hearing aids, nor was there a signed order from the otolaryngologist or attending physician. Additionally, there was no documentation showing that the current hearing aids were performing to specifications but no longer adequate for your hearing loss, nor was there documentation showing hearing improvement with new aids.   We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve the hearing aids.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for pathology services (88305, 88312) provided on September 1, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for pathology services. You say that the patient does not go to your laboratory, so he/she is not using out-of-network benefits as his/her participating doctor send you the specimens to process. The Plan denied your request. The Plan says the services were both rendered by a non-participating provider and referred by a non-participating provider. The Plan has also determined that these services were not urgent, emergent, nor were they approved in advance.  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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for pathology services (88305, 88312) provided on September 1, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on February 4, 2021.  You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are included in the dialysis rate. The Plan denied your request. The Plan says the tests are not separately reportable.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable.  We looked at the file and the rules. The records show that the lab services at issue were provided as part of the enrollee's ESRD treatment. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on April 12, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the home health aide or certified nurse assistant, providing care in the home; per hour (S9122) provided from August 2, 2021, to August 4, 2021.  You asked the Plan to reimburse you for the home health services. You say that the home care aide care that you received complies with your Evidence of Coverage. The Plan denied your request. The Plan says you must receive your care from a network provider and the provider must be eligible to participate in Medicare. The Plan also says that the provider in this case does not participate with Medicare.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the home health aide or certified nurse assistant, providing care in the home; per hour (S9122) provided from August 2, 2021, to August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fitness equipment provided on September 16, 2020.  You asked the Plan to pay for the services provided. You say that you discontinued your gym membership and purchased a stationary bike. The Plan denied your request. The Plan says the request was received outside of the acceptable window of submission.  The rules say that Medicare does not cover fitness benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the rules. The records show that reimbursement for the fitness equipment was received on August 31, 2021. Reimbursement requests were accepted by the Plan up to March 31, 2021. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the fitness equipment provided on September 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI).  You asked the Plan to pre-approve MRI. You say that the enrollee has weakness on her left side. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this scan is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.   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 MRI. Our reviewer says that the enrollee does not meet the criteria for the requested MRI. Our physician reviewer found there needs to be a detailed physical examination to meet criteria. Absent this, the requested MRI is not considered medically reasonable and 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.  You asked the Plan to pre-approve the requested LDCT scan. You say that this is medically necessary as you have a history of smoking. The Plan denied your request. The Plan says the criteria have not been met.  The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.      We reviewed the file and the Medicare rules. We find that in this case, you are older than the allowed age range of 55-77 years. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Apple Watch provided on August 24, 2021.  You asked the Plan to pay for the Apple Watch. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says an Apple Watch is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the Apple Watch provided on August 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a polysomnography (95810)  You asked the Plan to pre-approve the polysomnography. The Plan denied your request. The Plan says the request for coverage of a polysomnography (95810) is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that follow-up polysomnography or sleep studies are not routinely indicated for patients treated with Continuous Positive Airway Pressure (CPAP) whose symptoms continue to be resolved with CPAP treatment. Follow-up polysomnography studies may be indicated when clinical response is insufficient or when symptoms return despite a good initial response to treatment with CPAP.  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 polysomnography. Our reviewer says that an attended diagnostic polysomnography (95810) is not medically necessary. Our physician reviewer found the patient already has a diagnosis of Obstructive Sleep Apnea (OSA). Our reviewer found that this patient is having symptoms despite use of Continuous Positive Airway Pressure (CPAP), with a high residual Apnea-Hypopnea Index (AHI), indicating that CPAP at the current settings is not adequate. Our physician reviewer also found that what is needed is a split-night attended study including Positive Airway Pressure (PAP) titration (95811). 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 polysomnography have not been met. Therefore, we decided that the Plan does not have to pre-approve a polysomnography (95810)