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

 We decided that the Plan does not have to pre-approve additional Modivcare mileage.  You asked the Plan to pre-approve additional mileage. You say that you would like to see this doctor because you are having several complications with your breathing while sleeping and during the day and swallowing as well as swelling of the neck area. The Plan denied your request. The Plan says you are requesting an additional 52 miles for a total of 102 miles and your benefit only allows 50 miles.  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 up to 36 one-way trips and each one-way trip must not exceed 50 miles of driving distance.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare mileage.
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 enrollee would benefit from IRF care. The Plan denied your request. The Plan says the criteria for admission to the IRF setting have not been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.  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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on September 23, 2021 by an out-of-network (OON) provider.  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 were rendered by an out-of-network provider without prior authorization.  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 the laboratory services provided on September 23, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a diagnostic computerized tomography (CT) scan of the thorax without contrast material (72141).  You asked the Plan to pre-approve the CT scan. You say that the requested CT scan is medically necessary. The Plan denied your request. The Plan says the enrollee has already had a repeat CT imaging which revealed stability of the nodule more than 2 years after initial discovery. There is no evidence that another repeat CT scan is medically necessary at this time.  The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the documentation provided does not support medical necessity for the requested scan. Our physician reviewer found that the records show that the enrollee was a former smoker, but no quantification of pack years was noted, and it is not clear when she quit. No definite size of the calcified granuloma in the upper right lobe is given, and the Fleischner Society criteria for following incidental nodules indicates that a 2-year stability is satisfactory to ensure a benign etiology. In light of the calcification and the stable size of the nodule, additional surveillance does not appear necessary. She may be eligible for low dose CT depending on whether she satisfies CMS criteria for the test.  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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a diagnostic computerized tomography (CT) scan of the thorax without contrast material (72141).
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the percutaneous vertebral augmentation (22514) provided on December 4, 2020.  You asked the Plan to pay for the percutaneous vertebral augmentation. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that although the decision was untimely, they would have overturned if more time was available.  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. In this case, the Plan has not submitted a denial reason backed by Medicare coverage rules. Furthermore, the Plan has made it clear that there is no valid denial reason as they would have approved coverage given more time. Therefore, we decided that the Plan has to pay for the percutaneous vertebral augmentation (22514) provided on December 4, 2020.   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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home health flu shot.  You asked the Plan to pre-approve home health service. You say that you have a power chair and getting into a car is dangerous for you as you could possibly fall. You also say that you have chronic pain in your joints. The Plan denied your request. The Plan says this service can be provided at your primary care physician's office or a pharmacy. The Plan says  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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health service have not been met. Specifically, the file does not show that you require skilled services. Additionally, the Plan confirmed that there are no contracted home health agencies that administer flu vaccines. Therefore, we decided that the Plan does not have to pre-approve a home health flu shot.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on July 20, 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 Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 81455 are denied as not medically necessary.  We looked at the file and Medicare rules. The services are billed under code 81455. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (70450) provided on June 21, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  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 70450 is a column II code to column I code 70496. 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 services (70450) provided on June 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy rendered on August 23, 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 Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.   We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on August 23, 2021.   Benefits for these services 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tetanus vaccine rendered on September 1, 2021.  You asked the Plan to pay for these services. You say that you had a deep gash on your right leg and were due for a tetanus vaccine. The Plan denied your request. The Plan says the services were not billed with an appropriate diagnosis.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.   The file shows that the tetanus vaccine was billed with diagnosis code Z23 (encounter for immunization). This diagnosis does not support that you had a direct exposure to an illness requiring this vaccine. You may wish to contact the provider to request a corrected claim. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine rendered on September 1, 2021.   Benefits for these services 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for air ambulance services provided on July 2, 2021.  You asked the Plan to pay for air ambulance services. The Plan denied your request. The Plan says air ambulance services were not medically necessary.  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 air ambulance services. Our reviewer says that the air ambulance services were not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the enrollee suffered from an illness or injury that contraindicated transportation by any means other than ambulance. The enrollee was hemodynamically and neurologically stable on outpatient medications at the time of transport with no documentation in the provided records that transport by a commercial aircraft with use of a wheelchair was contraindicated. The documentation does support that the transferring hospital did not have adequate facilities to provide the medical services needed by 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 air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services provided on July 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services coded 37242 and 34712 provided on August 9, 2021.  You asked the Plan to pay for the medical services. You say that the documentation verifies the services as they were billed. The Plan denied your request. The Plan says the claim has not been coded correctly per 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, the CPT Code Manual definition of code 34712 is transcatheter delivery of enhanced fixation device(s) to the endograft (eg, anchor, screw, tack) and all associated radiological supervision and interpretation. The CPT Code Manual definition of code 37242 is vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms).  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 the medical services. Our reviewer says that the documentation does not support the services as billed. Our reviewer found for CPT 34712, the operative report does not include documentation of transcatheter delivery of enhanced fixation device. Therefore, this procedure cannot be verified. Regarding CPT 37242, the operative report does not describe per National Correct Coding Initiative Policy Manual a guidewire threaded through the needle into the vessel, needle removed, and catheter is threaded into the vessel and wire extracted. Catheter travels to the appropriate blood vessel and beads, coils or another vessel-blocking device are released. Operative report does not include enough documentation to confirm this procedure has been performed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded 37242 and 34712 provided on August 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an interspinous spacer placement procedure (22869, 22870).  You asked the Plan to pre-approve an interspinous spacer placement procedure. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested services are experimental/investigational.  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 interspinous spacer placement procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is an experimental/investigational procedure which two learned orthopedic societies have not endorsed.  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 interspinous spacer placement procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement procedure (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve consultation with an oral surgeon for extraction services.  You asked the Plan to pre-approve the oral surgeon consultation services. You say that you are in pain due to an abscess and have been waiting for an extraction. You say that the abscess is located on the jawbone, which makes it hard for a general dentist to remove. The Plan denied your request. The Plan says services from an oral surgeon are not a covered benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the coverage is limited to services performed by a general dentist. Therefore, we decided that the Plan does not have to pre-approve consultation with an oral surgeon for extraction services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic (D2740), core buildup, including any pins when required (D2950), resin-based composite - one surface, posterior (D2391), and resin-based composite - one surface, anterior (D2330) provided September 22, 2021.  You asked the Plan to provide additional payment for the crown, core buildup and fillings. You say that you need additional coverage. The Plan denied your request. The Plan says there is no coverage for core buildups and the remaining services were processed correctly according to your OON benefits.  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 fillings with 55% coinsurance and crowns with 75% coinsurance when provided out-of-network. You may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider.  We looked at the file and Medicare rules. The Plan provided documentation showing that they covered 45% of the allowed amount for the fillings and 25% of the allowed amount for the crown. Since the services were provided OON you are responsible for the difference between the Plan's allowed amount and the total cost billed by the OON provider. Though the Plan provides dental benefits in excess of Medicare coverage, the core buildup is not among those covered service. Therefore, we decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic (D2740), core buildup, including any pins when required (D2950), resin-based composite - one surface, posterior (D2391), and resin-based composite - one surface, anterior (D2330) provided September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for office visits, imaging, injections, and other outpatient services provided by a chiropractor from February 22, 2021, to May 10, 2021.  You asked the Plan to pay for chiropractic services. You say that these services were medically necessary and should be approved. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the records do not show that these services were medically necessary.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for office visits, imaging, injections, and other outpatient services provided by a chiropractor from February 22, 2021, to May 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650) for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that records show this is not a last resort for treatment of the enrollee's pain.

The Plan must follow Medicare rules. Medicare rules say that implantation of dorsal column or depth brain stimulators can be covered if Medicare criteria have been met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The patient does not have any evidence based indication for this procedure and has other therapeutic modalities available. The enrollee has not had a surgical consultation. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 

We looked at this physician'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 pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650) for the enrollee.