Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466)

You asked the Plan to pre-approve a home ventilator. You say that this is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

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 a home ventilator. Our reviewer says that a home ventilator is not medically reasonable and necessary. Our physician reviewer found this patient has a listed diagnosis of COPD, but there are no supporting pulmonary function data. The patient is morbidly obese and has mild CO2 retention in the setting of hospitalization for heart failure with pulmonary edema and pulmonary hypertension. Obesity hypoventilation syndrome is a likely contributing diagnosis. The patient does not have thoracic restrictive disease or neuromuscular disease. There is no mention of whether the patient might have obstructive sleep apnea. This patient may benefit from bilevel positive airway pressure (BiPAP) support at night, and certain BiPAP devices can provide the average volume-assured pressure support (AVAPS) mode of support. Medicare does not cover a ventilator when used as BiPAP. There is no evidence of BiPAP failure in the home setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466)
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz Fx.

You asked the Plan to pre-approve Supartz Fx. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Supartz Fx. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria 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 Supartz Fx have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz Fx.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services (procedure code 99214, 96127) provided to the enrollee on August 12, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill the claim as directed by Medicare.

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 the denied codes is: 

CPT 99214: 

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter. 

CPT 96127:

Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument 

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the provider reported 02 Telehealth for the place of service. Per Medicare "Place of Service (POS) of 02 to indicate telehealth should no longer be used." The intended originating site of where the service would have been provided. Also, modifier 95 should be appended as well, to identify telehealth services were furnished. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for telehealth services (procedure code 99214, 96127) provided to the enrollee on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accessories.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the items are considered benefit exclusions.

The Plan must follow Medicare rules. The rules say that power wheelchair options are only covered under certain medical conditions.

The file shows that a power seat elevation system and transit securement package. was requested. The requested items are non-covered because they are not primarily medical in nature. Based on this information, we decided that the Medicare rules for coverage have not been met.

The file shows that an attendant control was requested. If an attendant control is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. Based on this information, we decided that the Medicare rules for coverage have not been met.

The file shows that a lateral positioning wedge was requested, identified by code K0108. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The requested positioning wedge was not requested with the correct code or modifier. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve the requested power wheelchair accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 24, 2021, through June 25, 2021.  

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of an inpatient hospital admission does not meet the requirements for approval.  

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 24, 2021, through June 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the wound care provided from July 15, 2021, to July 22, 2021.  You asked the Plan to waive the copayments for the wound care. You say that you were billed for an ambulatory surgical procedure and not wound care services. You say you did not have a surgical procedure. The Plan denied your request. The Plan says you have been asked to pay 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). Your contract with the Plan clearly says that you must pay a $350 copayment per in-network visit. For these dates of service, you have been asked to pay the allowed amounts of the claim because this amount is less than the standard $350 copayment for the wound care.   You have been asked to pay a $326.36 copayment for the wound care on each date of service. The wound care falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the wound care is considered a surgical procedure.   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 copayments for the wound care from July 15, 2021, to July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lens fitting provided on October 8, 2021.

You asked the Plan to pay for contact lens fitting. The Plan denied your request. The Plan says contact lens fitting is an exclusion under your Plan.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that fitting for contact lenses is a prescription eyewear exclusion. Therefore, we decided that the Plan does not have to pay for contact lens fitting provided on
October 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto tablet 24-26mg 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 is denied as a benefit exclusion.

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 Entresto tablet 24-26mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the intracept procedure.  

You asked the Plan to pre-approve the intracept procedure. You say that significant clinical and diagnostic patient specific data in support of medical necessity has been submitted. You say that the requested procedure is medically necessary to provide relief for the enrollee's current symptoms. The Plan denied your request. The Plan says the requested services are considered experimental and investigational, as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature.  

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 intracept procedure. Our reviewer says that the intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental for low back pain. More research is needed to show safety and efficacy.  

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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on May 13, 2021.

You asked the Plan to reimburse you an additional amount for eyeglasses. The Plan denied your request. The Plan says a check in the amount of $150 was sent to you on July 13, 2021. The Plan says that the Plan is not required to reimburse any amount over the allowed amount $150 and the difference is the member's responsibility.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the Plan has reimbursed you the correct eyewear allowance of $150 and you are responsible for the difference. Therefore, we decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on May 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the proctosigmoidoscopy procedure you had at an outpatient hospital clinic on September 16, 2021.sue is "a power wheelchair provided by The Wheelchair Store on January 12, 2016."  You asked the Plan to reduce the copayment for the proctosigmoidoscopy procedure. You say that you thought the copayment would just be like a regular office visit since this was done in the doctor's office and not a hospital. 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 $350 copayment for outpatient surgery and services provided at hospital outpatient facilities.    You have been asked to pay a $350 copayment for the proctosigmoidoscopy procedure. The facility where you had this service is an outpatient hospital clinic. That is why the proctosigmoidoscopy procedure falls within the outpatient surgery and services provided at hospital outpatient facilities 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 reduce the copayment for the proctosigmoidoscopy procedure you had at an outpatient hospital clinic on September 16, 2021.sue is "a power wheelchair provided by The Wheelchair Store on January 12, 2016."
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder Detect test (0013M) provided on May 24, 2021.

You asked the Plan to pay for the Cxbladder Detect test (0013M). You say that the Cxbladder Detect test (0013M) was medically necessary. The Plan denied your request. The Plan says Cxbladder Detect test does not meet Medicare coverage criteria.

The Plan follows Medicare rules. Medicare rules say that to support the medical necessity of the service, there must be acceptance/uptake of specific testing into patient management.

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 Cxbladder Detect test (0013M). Our reviewer says that the Cxbladder Detect test is not medically necessary. Our physician reviewer found that the clinical documentation is insufficient to demonstrate that the Cxbladder Detect test provided will be used to assist in the management/treatment of the enrollee in this case. 

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 Cxbladder Detect test (0013M) have not been met. Therefore, we decided that the Plan does not have to pay for the Cxbladder Detect test (0013M) provided on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional periapical x-rays (D0230 x 3) provided on May 20, 2021.
You asked the Plan to pay for the dental services. You say that you are supposed to have dental coverage. You also say that this is not coverage, but it is a small discount. The Plan denied your request. The Plan says 1 periapical x-ray is covered at 50% when received out of network. The Plan also says that the frequency limit has been exceeded.
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 and periapical x-rays are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid 50% towards the initial periapical x-ray that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the additional periapical x-rays (D0230 x 3) provided on May 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-emergency round trip ambulance transport to a physician's office.

You asked the Plan to pre-approve a non-emergency round trip ambulance transport to a physician's office. You say that the requested round trip non-emergency ambulance transport to a physician's office is medically necessary. The Plan denied your request. The Plan says the requested round trip non-emergency ambulance transport to a physician's office is not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a non-emergency round trip ambulance transport to a physician's office. Our reviewer says that the requested round trip non-emergency ambulance transport to a physician's office is not medically necessary. Our physician reviewer found the enrollee is with a past medical history of dementia, atrial fibrillation, colon cancer, and chronic kidney disease. The enrollee underwent arthroscopic extensive debridement and synovectomy of the right shoulder for septic arthritis on November 16, 2021. 

The documentation does not support that another means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) are contraindicated for the enrollee in this case. The documentation does not support that the requested ambulance transport to a physician's office is medically reasonable and necessary for the enrollee in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a non-emergency round trip ambulance transport to a physician's office have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-emergency round trip ambulance transport to a physician's office.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a visual field test provided on August 19, 2021.

You asked the Plan to waive the copayment for the visual field test. The Plan denied your request. The Plan says the claim paid with the correct copayment for a specialist office visit.

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 $10 copayment for Vision Care. 

You have been asked to pay a $10 copayment for the visual filed test. The visual filed test falls within the Vision Care 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 a visual field test provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit with an endocrinologist you had on September 10, 2020.

You asked the Plan to waive the copayment for the endocrinology visit. You say that this was a telehealth visit and you thought the copayment was waived due to COVID-19. 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 visits with a specialist. 

You have been asked to pay a $45 copayment for the endocrinology visit. The endocrinology visit falls within the visits with a specialist benefit category. Please note that the Plan's website explicitly states that telehealth visits during the COVID-19 pandemic are available at the same cost sharing as in-office visits. 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 visit with an endocrinologist you had on September 10, 2020.