Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the services related to multiple myeloma (cancer of the plasma cells) (CPT code(s): 80053, 84550, 85025, 96413, J9176, and 96375) to be provided from February 1, 2022, through April 30, 2022, by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services. You say that the treatments are lifesaving to treat cancer and you indicate this service is keeping you alive and must be administered while you are living in Florida for three months. The Plan denied your request. The Plan says that as your multiple myeloma was diagnosed prior to you leaving the area and is not an unforeseen medical illness, injury, or condition that requires immediate medical care, this is foreseen care, and the request is denied. The Plan states you may obtain some services from an out-of-network provider, out of our service area using your point of service benefit. The Plans states that doing so may result in a higher cost share and is subject to any copayment and/or coinsurance as defined in Chapter 4 of your Evidence of Coverage.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the out-of-network services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you require ongoing regular treatments that cannot wait three (3) months for your return. Considering your multiple myeloma required ongoing testing and chemotherapy, it has to be continued in Florida while you are away due to the length of time until returning home. That would delay treatment too long increasing your risk of progression of your disease. 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 out-of-network services have been met. Therefore, we decided that the Plan has to pre-approve the services related to multiple myeloma (cancer of the plasma cells) (CPT code(s): 80053, 84550, 85025, 96413, J9176, and 96375) to be provided from February 1, 2022, through April 30, 2022, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 27,
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 units billed were inappropriate.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.

In this case, the MUE for CPT code 34203 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. 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 surgical services
provided to the enrollee on August 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (84443) provided on August 31, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is a duplicate service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan argues the services in question (84443) were billed as a duplicate claim line. However, these services were provided by two different providers. As such, this is not considered to be a duplicate service according to Medicare rules. Therefore, we decided that the Plan has to pay for the services (84443) provided on August 31, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive eye exam you had on September 30, 2021.

You asked the Plan to waive the copayment for the comprehensive eye exam. You say that this copayment is a hardship for you. The Plan denied your request. The Plan says you were charged this copayment correctly.

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 $45 copayment for vision services with a specialist. 

You have been asked to pay a $45 copayment for the comprehensive eye exam. The comprehensive eye exam falls within the vision services with a specialist 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 the comprehensive eye exam you had on September 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a transthoracic echocardiogram (93306) provided to the
enrollee on June 22, 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 this was billed by another provider within the inpatient stay, and is not separately reimbursable.
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 93306 is "Echocardiography, transthoracic, real-time
with image documentation (2D), includes M-mode recording, when performed, complete, with spectral
Doppler echocardiography, and with color flow Doppler echocardiography."
We find that CPT code 93306 is not supported in the medical record. Specifically, this service was rendered
during the enrollee's inpatient stay, which means that it is not separately reportable and reimbursable. 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 a transthoracic echocardiogram (93306) provided to the enrollee
on June 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular artery embolization (CPT code(s): 37243,
36247, and 76937).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says there are not enough studies on geniculate artery embolization for treatment of knee
osteoarthritis to show it is safe and effective.
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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable, and
comprehensive less invasive conservative care measures. Regardless, there is limited published, large-scale,
long-term peer-reviewed literature that shows the requested geniculate artery embolization to be an effective
and/or safe treatment for knee osteoarthritis. There is no compelling rationale presented or extenuating
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore,
the request for genicular artery embolization (37243, 36247, 76937) is 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 have not been met. Therefore, we decided that the Plan does not
have to pre-approve genicular artery embolization (CPT code(s): 37243, 36247, and 76937).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper extremity orthosis (L3982), delivery (A9901), and education and training (98960), provided on July 20, 2021.
You asked the Plan to pay for the upper extremity orthosis, delivery, and education and training. You say that the items were medically necessary. The Plan denied your request. The Plan says this provider is on the Federal Exclusion list.
The Plan must follow Medicare rules. Medicare rules say that section 1128 of the Social Security Act provides the authority to Medicare to exclude various health care providers from receiving payment under Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the upper extremity orthosis, delivery, and education and training have not been met. Specifically, this provider is listed on the Federal Exclusion list as of March 16, 2021.
No payment is made to anyone for any items or services in any capacity furnished, ordered, or prescribed by an excluded party under the Medicare program. Therefore, we decided that the Plan does not have to pay for the upper extremity orthosis (L3982), delivery (A9901), and education and training (98960), provided on July 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from August 25, 2021, to August 26, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you should not be responsible for the noncovered items or services that should have been covered under your Part D plan.
The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
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 the self-administered drugs provided in an outpatient setting from August 25, 2021, to August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically
necessary. The Plan denied your request. The Plan says a LTACH admission is not medically necessary.
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 that the enrollee was admitted with acute hypoxic respiratory failure due to bacterial
pneumonia. The record indicates that the enrollee continues to require acute care services as she is still
hypoxic, and the x-rays demonstrate worsening pulmonary infiltrates. The enrollee continues to receive acute
care services, and these have not been denied. The medical record does not indicate that the enrollee requires
services that she is not currently receiving but that would be available at the LTACH facility. The elements of
the coverage rules are not satisfied. The requested service cannot be recommended.
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), trifocal lenses (V2300, V2303), anti-reflective lenses (V2750) and a miscellaneous vision service (V2799) provided on July 28, 2021.
You asked the Plan to pay for eyeglass frames, trifocal lenses, anti-reflective lenses and a miscellaneous vision service. You say that you called the provider's office and asked if the exam and frames were covered. You were assured they were covered. The Plan denied your request. The Plan says you exhausted your $150 vision allowance benefit, and you are responsible for the remaining balance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says you receive a $150 allowance toward the purchase of eyeglass frames, eyeglass lenses and contact lenses, fitting, and dispensing, every 24 months. We looked at the file and the Plan's rules. The records show you exhausted your $150 maximum allowed benefit on July 28, 2021. The records also show you purchased eyeglass frames at $130, trifocal lenses at $179.50 each lens, anti-reflective coating at $20 and a miscellaneous vision service at $15, for a total amount of $524 ($130 + $179.50 + $179.50 + $20 + $15 = $524). The Plan applied your $150 allowance which left you with a balance of $374 ($524 - $150 = $374). Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, trifocal lenses, anti-reflective lens and a miscellaneous vision service have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), trifocal lenses (V2300, V2303), anti-reflective lenses (V2750) and a miscellaneous vision service (V2799) provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466).

You asked the Plan to pre-approve the home ventilator. You say that the enrollee is at very high risk of this condition worsening aiding in the deterioration of their health, and this may lead to possible hospitalization or death without NiV. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in intelligent volume-assured pressure support (IVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 home ventilator. Our physician reviewer found a home ventilator is not medically necessary. This enrollee has severe obstructive sleep apnea (OSA), on BiPAP treatment during sleep, but also has carbon dioxide (CO2) retention on an arterial blood gas done while the enrollee was awake and stable. There is a listed diagnosis of chronic obstructive pulmonary disease (COPD), but pulmonary function tests show restriction, not obstruction. The enrollee is severely obese and has an elevated hemidiaphragm on imaging. The CO2 retention is likely related to a combination of obesity-hypoventilation syndrome and restrictive lung disease. A component of COPD is possible, but this does not appear to be the primary reason for the CO2 retention. The enrollee does not have generalized neuromuscular disease or thoracic restrictive disease. The enrollee may benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep. There is no evidence that this has been tried. Medicare does not cover a ventilator when used as BiPAP. The denial of the ventilator is upheld.

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120) and prophylaxis (D1110)
provided on October 16, 2021, by the non-participating provider.
You asked the Plan to pay for the dental services. You say that you cannot open your mouth. You also say that
your current dentist has adjusted to how to work with you. The Plan denied your request. The Plan says dental
services are only covered when performed by a participating provider.
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 oral exam and prophylaxis are not
among those covered under this benefit when performed by a non-participating provider. Therefore, we
decided that the Plan does not have to pay for the periodic oral exam (D0120) and prophylaxis (D1110)
provided on October 16, 2021, by the non-participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the
enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care such as at a
skilled nursing facility, on an intermittent basis at home with home health care, or in a long-term care 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for. transverse myelitis and was transferred to skilled nursing on February 24, 2022. Medical
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is
no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that
this enrollee 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on February 2, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Next Generation Sequencing is covered for the indications established in the applicable NCD. 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 testing. Our reviewer says that the requested genetic testing is not medically reasonable and necessary in this case. Our physician reviewer found that the records do not document that the enrollee's malignancy was either recurrent, relapsed, refractory, metastatic or advanced stage III or IV cancer, to meet criteria for coverage. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 2, 2021.