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

 We decided that the Plan does not have to pay for the ambulance transport provided on February 1, 2021.  You asked the Plan to pay for the ambulance transport. You say that the enrollee was transported from her residence to the elementary school for a Coronavirus immunizations due to her bed confinement. The Plan denied your request. The Plan says the elementary school where the member was transported is not a covered destination.  The Plan's denial rationale in this case is not applicable during the Coronavirus Public Health Emergency (PHE).  As noted in the rules, Medicare has expanded covered destinations for ambulance services to any location that can provide care to the member during the course of the PHE.  However, members must still meet medical necessity requirements for ambulance transport. Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ambulance transport. Our reviewer says that this patient did not require ambulance transportation. Our physician reviewer says that documentation does not support that other means of transport (such as stretcher van) were contraindicated for this patient on February 1, 2021. In addition, the physician reviewer stated that the patient did not need the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance could provide for safe transport on February 1, 2021. The patient was hemodynamically stable and did not require any medical services before, during, or after transportation. Home oxygen could have been brought during transport. Therefore, the documentation does not support that the ambulance transport on February 1, 2021 was medically reasonable and necessary for the patient.  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 ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transport provided on February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on January 18, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81317, 81401, 81301, 81191, 81309, and 81445. Codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81317, 81401, 81301, 81191 and 81309 are column II codes with a modifier indicator of 1 when billed with column I code 81445. The column II codes were not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Cosentyx pen injector 300 dose for the enrollee.  You asked the Plan to pre-approve the pen. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is self-administered.  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 Cosentyx pen injector 300 dose for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.  You asked the Plan to pre-approve the inpatient psychiatric hospital services. You say that the documentation provided justifies the enrollee's need for inpatient psychiatric treatment. You say that the enrollee remains gravely disabled and continues to be a danger to himself. The Plan denied your request. The Plan says the enrollee's benefit limit for inpatient psychiatric hospital care has been exhausted.  The Plan must follow Medicare rules. Medicare rules say that there is a lifetime maximum of 190 days on inpatient psychiatric hospital services available to any beneficiary.  We looked at the file and Medicare rules. The case file shows that, as of November 17, 2021, the enrollee has received coverage for 190 days of inpatient psychiatric hospital care. This means that the maximum lifetime benefit for these services has been exhausted. Based on this information, we decided that Medicare rules for coverage of the inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Enbrel Sureclick solution, 50 mg/ml.  You asked the Plan to pre-approve Enbrel Sureclick. You say that the enrollee needs this to continue their treatment for rheumatoid arthritis. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is 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 pre-approve Enbrel Sureclick solution, 50 mg/ml.   Benefits for Enbrel Sureclick 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the coinsurance for dialysis training services (procedure code 90993) provided from January 1, 2021, through March 31, 2021.  You asked the Plan to waive the coinsurance for dialysis training services. You say that you were not aware of the changes in reimbursement. You say had you known, you would have changed policies. The Plan denied your request. The Plan says that 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). The enrollee's contract with the Plan says that enrollees must pay zero coinsurance or copayment for kidney disease education services with an in-network provider.   The record shows the provider is in-network with the Plan. The Plan says the enrollee must pay 20% coinsurance for dialysis education services. Based on the plan contract, however, the enrollee cannot be asked to pay more than zero coinsurance or copayment for dialysis education services. Therefore, we decided that the Plan has to waive the coinsurance for dialysis training services (procedure code 90993) provided from January 1, 2021, through March 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that your feet hurt and need the custom orthotics because your bones changed position. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Victoza for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is on the self-administered list.  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 Victoza for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on November 27, 2020.  You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications.  While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on November 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional routine transportation trips.  You asked the Plan to pre-approve additional routine transportation trips. You say that the requested transportation services are medically necessary. The Plan denied your request. The Plan says your benefit for routine transportation trips has been exhausted.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 one-way routine transportation trips per year.   We looked at your request, the records in the case file, and the rules. The records show that you received coverage for 48 one-way routine transportation trips in the 2021 calendar year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown (D2750) for tooth # 29, and core build up (D2950) for teeth # 29 and 30 provided on June 10, 2021.  You asked the Plan to pay for the crown for tooth # 29 and core build up for teeth # 29 and 30. You say that the plan should cover at least half. The Plan denied your request. The Plan says the crown for tooth # 29 and the core build up for teeth # 29 an 30 are not necessary.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown for tooth # 29 and core build up for teeth # 29 and 30 when the services are medically necessary and reasonable.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the crown for tooth # 29 and core build up for teeth # 29 and 30. Our reviewer says that the crown for tooth # 29 and core build up for teeth # 29 and 30 are not medically necessary. Our physician reviewer found There is no clear issue with tooth #30 other than recurrent decay at the distal margin, and although a replacement crown was authorized there is no indication that there is insufficient structure remaining to support a new crown.  A core buildup is only necessary where there is less than 50% structure and there would be insufficient retention to retain a crown.    A core buildup is not indicated unless a crown cannot be retained, which has not been shown in this instance. Therefore, the reviewer found that the core build up for tooth # 30 is not medically necessary. The reviewer found that there is insufficient damage to tooth # 29 as to require a crown as the majority of the tooth is still intact. The reviewer also found there is no necessity for a core and a crown on # 29.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown for tooth # 29 and core build up for teeth # 29 and 30 have not been met. Specifically, the file shows that there is sufficient structure to retain a crown on teeth # 29 and 30. Additionally, the file shows that tooth # 29 does not have sufficient breakdown on warrant a crown for tooth # 29. Therefore, we decided that the Plan does not have to pay for the crown (D2750) for tooth # 29, and core build up (D2950) for teeth # 29 and 30 provided on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) for tooth #14 to be provided by an out-of-network (OON) provider.  You asked the Plan to pay for the crown and core buildup. You say that your provider should be in-network. The Plan denied your request. The Plan says the services are not covered when provided OON.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown and core buildup when the services are provided by a network dentist.   We looked at the file and Medicare rules. The Plan provided documentation showing that this dentist is not part of the Plan's dental network in 2021. Based on this information, we decided that the Plan's rules for coverage of the crown and core buildup have not been met. Therefore, we decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) for tooth #14 to be provided by an out-of-network (OON) provider.   Your complaint about potentially being provided misinformation about the network status of the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit coded 99202 provided on June 21, 2021.  You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.  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 99202 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 office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99202 provided on June 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve four (4) additional PT visits.  You asked the Plan to pre-approve four (4) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.  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 pre-approve four (4) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the medical records provided, there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based on the available records, the enrollee appears to have plateaued with therapy. Further utilization of the home exercise program appears appropriate at this point. The provided records do not clarify why the physical therapy visits that the enrollee has already had, plus the four additional visits that have been approved are inadequate to treat the enrollee's condition. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of four (4) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) additional PT visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  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 medical, nursing, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While the enrollee may require physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that the 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental services received on June 17, 2021 and June 21, 2021.  You asked the Plan to pay for the dental services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.  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 the dental services received on June 17, 2021 and June 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for knee arthroscopy provided to the enrollee on March 19, 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 a separate charge for CPT 29877 is not eligible for payment.  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 29877 is "Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)."    We find that CPT code 29877 is not supported in the medical record. Specifically, this code cannot be billed separately from CPT 29880. 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 knee arthroscopy provided to the enrollee on March 19, 2021.