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

We decided that the Plan does not have to pay for an electric seat lift mechanism (E0627) with delivery and set-up fees (A9901) and sales tax (S9999) provided on June 3, 2021, by a supplier not enrolled in the Medicare program.
You asked the Plan to pay for an electric seat lift mechanism with delivery and set-up fees and sales tax.. You say that the item at issue is a necessity for your care. The Plan denied your request. The Plan says rules for payment have not been met because the supplier of the item at issue is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for an electric seat lift mechanism (E0627) with delivery and set-up fees (A9901) and sales tax (S9999) provided on June 3, 2021, by a supplier not enrolled in the Medicare program
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of interbody biomechanical device(s) services 
coded 22853 provided on February 22, 2021. 
 
You asked the Plan to pay for the insertion of interbody biomechanical device(s) services. 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 supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. We find that 3 units of CPT code 22853 are not supported in the medical record. The medical record only 
supports 3 units of CPT code 22853. Based on this information, we decided that Medicare rules for coverage of 
the insertion of interbody biomechanical device(s) services have not been met. Therefore, we decided that the 
Plan does not have to pay for the insertion of interbody biomechanical device(s) services coded 22853 provided 
on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152 and 99153 provided on December 25, 2020.
You asked the Plan to pay for the moderate sedation services. 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 supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT codes 99152 and 99153 are not supported in the medical record. Specifically, code 99153 is not separately payable when performed by a physician in a facility setting. The medical records provided were not for the correct date of service for this claim; therefore, code 99152 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152 and 99153 provided on December 25, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical and related medical services provided from 
March 22, 2021, to March 24, 2021. 
 
You asked the Plan to pay for the medical services. You say that these claims should be reprocessed and 
approved for payment. The Plan denied your request. The Plan says these claims have denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that in most cases, inpatient procedures billed on an 
outpatient claim will be denied. Line items then billed on the same date of service will be denied. 
 
We looked at the file and Medicare rules. In this case, you have billed code 38724, an inpatient procedure, on 
an outpatient claim. There are no exceptions here that would allow this inpatient service to be billed on an 
outpatient claim. All remaining lines for the same date of service were denied based on the OCE edit. 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 surgical and related medical services provided from March 22, 2021, 
to March 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on May 6, 2021.
You asked the Plan to pay for the ambulance service. You say that you were in a bicycle accident. You say that if you had gone to the hospital, it would have cost the plan a lot more. You also say that you feel this should be covered. The Plan denied your request. The Plan says because the Medicare ambulance benefit is a transport benefit, if no transport is provided, then there is no Medicare covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 6, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic continuous glucose monitor (CGM) supplies provided on April 30, 2021.
You asked the Plan to pay for therapeutic CGM supplies. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these supplies is correct, because the enrollee did not meet the Medicare criteria for a therapeutic continuous glucose monitor (CGM).
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic continuous glucose monitor (CGM) supplies provided on April 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on June 30, 2021.
You asked the Plan to pay for CT scan 70450. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 70450 has a procedure-to-procedure (PTP) edit with code 70496 and is not separately payable without an appropriate modifier. 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 CT scan 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 a computed tomography (CT) scan (70450) provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the abutment supported crown (D6058 x 3) and abutment supported retainers (D6068 x 3) provided on May 26, 2021.
You asked the Plan to pay for the abutment supported crowns and retainers. You say that these services should be covered. The Plan denied your request. The Plan says the abutment supported crowns are not listed as covered services. The Plan says that abutment supported retainers are not listed as covered services either.
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 crowns and retainers are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the abutment supported crown (D6058 x 3) and abutment supported retainers (D6068 x 3) provided on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) provided on July 13, 2021.
You asked the Plan to pay for the dental service. You say that this service is covered. The Plan denied your request. The Plan says the custom fabricated abutment is not listed as a covered service.
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 custom fabricated abutment is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057) provided on July 13, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on March
25, 2021.
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 a covered
benefit.
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 March 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy. You say that the requested services are a medical necessity for the enrollee The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.
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 additional physical therapy. 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 the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what has already been approved by the Plan. The enrollee has had prior therapy of 40 outpatient visits and the records do not demonstrate 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 by or under the supervision of a therapist. The requested services are not part of a maintenance program, nor are the specialized skill, knowledge, and judgment of a qualified therapist 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 additional physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency, basic life support (BLS), ambulance 
transportation (A0428 x 2), ground mileage (A0425 x 2), and BLS supplies (A0382) provided on April 6, 2021. 
 
You asked the Plan to pay for the transportation services. You say that authorization was obtained to provide 
the services to the enrollee. The Plan denied your request. The Plan says the ambulance transport was 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 pay for the transportation services. Our reviewer 
says that the transportation services are not medically necessary. Our physician reviewer found that the 
provided documentation did not support that other means of transport (such as stretcher van, wheelchair van, 
taxi, private car, or other type of vehicle) were contraindicated for the enrollee on April 6, 2021. The reviewer 
found that the documentation did 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 April 6, 2021. 
The reviewer also found that the documentation did not support that the ambulance transport on April 6, 2021, 
was medically reasonable and necessary for 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 the transportation services have not been met. Specifically, the file shows that 
other means of transport were not contraindicated for the enrollee on the date of service in this case. Therefore, 
we decided that the Plan does not have to pay for the non-emergency, basic life support (BLS), ambulance 
transportation (A0428 x 2), ground mileage (A0425 x 2), and BLS supplies (A0382) provided on April 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto. 
 
You asked the Plan to pre-approve Entresto. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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.  
 
Benefits for Entresto 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: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve physical therapy.
You asked the Plan to pre-approve the physical therapy visits. You say that the contract provider is 17 miles
away and three visits a week would not be manageable. The Plan denied your request. The Plan says that the
17-mile distance is considered reasonable by Medicare criteria.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is
considered accessible to an enrollee if contract providers are available within reasonable distance and travel
time from the enrollee's home. The Plan says that enrollees must use contract providers.
The provider is a non-contract provider. We were able to confirm that the Plan does not have contract providers
located within reasonable distance and travel time from your home who can provide the physical therapy visits.
The record shows the distance criteria for your area is 10 miles for physical therapy. Under Medicare rules, this
means that contract providers are not accessible to you. Therefore, we decided that the Plan has to pre-approve
physical therapy to be provided by the out-of-network provider.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance transportation (A0427) and ground mileage (A0425) provided on February 12, 2021.
You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice on the date of service. The Plan denied your request. The Plan says during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on February 6, 2021. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the emergency
ambulance transportation (A0427) and ground mileage (A0425) provided on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided by an opted-out physician on
June 21, 2021.
You asked the Plan to pay for dermatology services. You say that you did not know this provider opted out of
Medicare. The Plan denied your request. The Plan says the denial of payment for these services is correct,
because this provider has opted out of the Medicare program and is not payable.
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
dermatology services provided by an opted-out physician on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for special anesthesia services (99100, 99140) provided on April 15, 2021.
You asked the Plan to pay for anesthesia. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these codes are always bundled for payment and are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that codes 99100 and 99140 are always bundled for payment. We looked at the file and Medicare rules. These codes are always bundled for payment and are not separately payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia services (99100, 99140) provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and refraction provided by an out-of-network provider on March 11, 2021.
You asked the Plan to pay for the eye exam and refraction. You say that authorization is not required for an exam and the claim should be reprocessed. The Plan denied your request. The Plan says in-network providers were available.
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 eye exam and refraction provided by an out-of-network provider on March 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. 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.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services