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

We decided that the Plan does not have to pay for the ambulance services (CPT code(s): A0425 and A4028) provided to the enrollee on March 30, 2021.
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated at the hospital for altered mental status and the enrollee required ambulance transport due to a risk of wandering or eloping, and a danger to themself. The Plan denied your request. The Plan says the destination is not recorded on the ambulance run report and the enrollee could have been safely transported by another type of motor vehicle, possibly a van transport vehicle.
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 services. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated for this enrollee on March 10, 2021. The documentation does not support
that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on March 10, 2021. No treatment was provided during this non-emergent transport. Restraints and supervision could be offered via other means of transport. The documentation does not support that the ambulance transport on March 10, 2021 was medically reasonable and necessary for the enrollee based on the provided documentation. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services (CPT code(s): A0425 and A4028) provided to the enrollee on March 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on March 19, 2021.
You asked the Plan to pay for excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm (21011) and (21011-59) x3. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the operative report did not include documentation of an excision of a tumor from the subcutaneous soft tissue of the face or scalp less than 2cm.
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 21011 is Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm. 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 excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm (21011) and (21011-59) x3. Our reviewer says that documentation submitted was reviewed and does not meet criteria for reimbursement. Our reviewer found operative report documents cysts were removed in Posterior left parietal, right mid parietal, posterior right parietal, and right occipital. CPT 21011 is an incorrect code to report for these procedures. The correct code should be reported from the benign lesion excision section for the removal. Cysts are dermal in origin, even if extends into subcutaneous tissue, and are not considered soft tissue tumors. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm (21011) and (21011-59) x3 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services provided on March 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for aortograpy (code 75625) provided on April 27, 2021.
You asked the Plan to pay for aortography. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the records do not support the code 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, the CPT Code Manual definition of code 75625 is aortography, abdominal, by serialography, radiological supervision and interpretation. 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 aortography.
Our reviewer says that this service does not meet the Medicare criteria for coverage. Our reviewer found per the National Correct Coding Initiative Policy Manual in regards to CPT code 75625, a local anesthetic is applied over the common femoral artery. The artery is percutaneously punctured with a needle and a guidewire is fed through the artery into the abdominal aorta. A catheter is threaded over the guidewire to the point of study and the guidewire is removed. Contrast medium is injected, and films are taken by serialography, producing a series of individual x-ray films. This code reports the radiological supervision and interpretation. Use a separately reportable code for the catheterization. This description was not documented in the operative note. The records provided do not include sufficient documentation to validate that an aortography, abdominal, by serialography, radiological supervision and interpretation was performed on April 27, 2021; therefore, this procedure cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of aortography have not been met. Therefore, we decided that the Plan does not have to pay for aortograpy (code 75625) provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve office visits with an out of network (OON) provider.
You asked the Plan to pre-approve the OON office visits. You say that you are requesting to see this OON provider because they are the only one who specializes in your specific cancer. The Plan denied your request. The Plan says that the requested OON provider does not provide any specialty that their network provider cannot provide. The Plan says that their network provider has appointments available within a week and is within the Medicare allowable distance.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 OON office visits. Our reviewer says that the criteria for coverage of OON care have been met. Our physician reviewer found the Plan's denial is not medically justified on the basis that it is not offering adequate care to meet the enrollee's medical needs through referral to their in-network provider. The enrollee's treating medical oncologist noted limited treatment options. The enrollee's condition is unique, and the Plan has not shown that their in-network referral meets the Standards of Care required for treatment of the enrollee's condition.
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 OON office visits have been met. Therefore, we decided that the Plan has to pre-approve office visits with an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home delivered meals.
You asked the Plan to pre-approve the home delivered meals. You say that you need food and the doctor will be upset for not getting the meals. The Plan denied your request. The Plan says you have exhausted the home-delivered meals benefit for this calendar year.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home delivered meals have not been met. Specifically, you have already received home delivered meals on July 1, 2021, July 8, 2021, July 15, 2021 and July 22, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve additional home delivered meals.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits.
You asked the Plan to pre-approve home health care. You say that this is medically necessary. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this home health care is not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve home health care. Our reviewer says that the enrollee does not meet the Medicare criteria for this home health care. Our physician reviewer found there is no documentation of any recent inpatient hospitalizations, recent change in the treatment plan, or recent face-to-face evaluation by the enrollee's treating physician. There is no documentation provided to assess skilled nursing needs except routine care given. The records do not show that skilled nursing or skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition or establish/perform a maintenance program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705) provided to the enrollee on May 23, 2021.
You asked the Plan to pay for the abdominal ultrasound. You say that these services were done multiple times on the date of service. The Plan denied your request. The Plan says the service is 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 abdominal ultrasound have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705) provided to the enrollee on May 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an evaluation with an out-of-network dentist.
You asked the Plan to pre-approve an out-of-network dental evaluation.. You say that you are in severe pain, unable to eat and are having trouble sleeping. You say that there is not a participating provider within two hours who skilled to perform the surgery. The Plan denied your request. The Plan says out-of-network dental services are not covered.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an evaluation with an out-of-network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for a service dog.
You asked the Plan to pre-approve coverage for a service dog. You say that the patient has been diagnosed with bilateral profound hearing loss and would benefit from a service animal. The Plan denied your request. The Plan says the enrollee does not have an eligible condition for the Service Dog Support benefit.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a service dog have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve coverage for a service dog.
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 disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for lumbar decompression and fusion. He is now medically stable with no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: Favorable

We decided that the Plan has to waive the copayment for the laboratory work provided on April 2, 2021.
You asked the Plan to waive the copayment for the laboratory work. You say that you did not have laboratory work done on this date of service. You would like to see the laboratory report. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.
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 did not submit the medical records. This means we cannot determine if the service was rendered on April 2, 2021. Therefore, we decided that the Plan has to waive the copayment for the laboratory work provided on April 2, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services provided on January 4, 2021.
You asked the Plan to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no documentation of critical care time spent to corroborate the services.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 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 critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291). Our reviewer says that documentation submitted was reviewed and does not meet requirements for reimbursement. Our reviewer found documentation does not document time spent providing critical care, and therefore 30--74 minutes cannot be confirmed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) have not been met. Therefore, we decided that the Plan does not have to pay for critical care services provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic services with an out of network (OON) provider.
You asked the Plan to pre-approve the OON therapeutic services. You say that you have been advised that the requested OON provider is the best facility for your back condition. The Plan denied your request. The Plan says the treatment of pain and weakness through exercise and other therapies may be provided by an in-network provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 OON therapeutic services. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the health plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through referral to an in-network physical therapist. There is no documentation that there is anything unique about the enrollee's condition that would make it medically necessary for him to see the requested OON provider. The Plan has shown that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's condition. 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 OON therapeutic services have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic services with an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a COVID-19 vaccine provided April 8, 2021.
You asked the Plan to pay for the COVID-19 vaccine. You say that the claim should be paid. The Plan denied your request. The Plan says Original Medicare is liable for this service.
The Plan must follow Medicare rules. Medicare rules say that for patients enrolled in a Medicare Advantage Plan in 2020 and 2021, providers must submit COVID-19 vaccine administration claims to Original Medicare. We looked at the file and Medicare rules. This service must be billed to Original Medicare. Based on this information, we decided that Medicare rules for coverage of the COVID-19 vaccine have not been met. Please note that the enrollee cannot be held liable for this service. Therefore, we decided that the Plan does not have to pay for a COVID-19 vaccine provided April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five extractions and an immediate upper denture.
You asked the Plan to pre-approve five extractions and an immediate upper denture. You say that the teeth are failing and there are not enough teeth to warrant a partial. You say that under your direction the patient wishes for removing the teeth and receiving an immediate denture. The Plan denied your request. The Plan says the service is 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve five extractions and an immediate upper denture.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that the rides are to get life-saving dialysis 3 times a week for the rest of your life. You say you have no other way to get there. The Plan denied your request. The Plan says the benefit only allows for twelve (12) trips.
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.
We looked at your request, the records in the case file, and the rules. The Plan benefit covers up to twelve (12) one-way trips. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 Vyzulta.
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.