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

We decided that the Plan does not have to pay forthe ambulance services provided on October 7, 2019.You asked the Plan to pay forthe ambulance services to and from aphysician's office. You say that the Plan should pay this claim.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on October 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture (D5213) provided on January 23, 2020. You asked the Plan to pay for the maxillary partial denture. You say that this service was approved in 2019, but the partial was not installed until January 23, 2020. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 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. The records show that the maxillary partial denture (D5213) was approved on October 29, 2019 based on your 2019 plan benefits. The authorization clearly states that allowances indicated may vary if plan benefits change prior to performance of these services and you must be eligible for benefits when the services are deemed incurred. It also states to refer to benefit plan documents for information regarding eligibility, frequency of benefits and claims information. Since the services were received in year 2020, they were processed based on 2020 plan benefits. Therefore, we decided that the Plan does not have to pay for the maxillary partial denture (D5213) provided on January 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve air ambulance transportation services.You asked the Plan to pre-approve the requested transportation. You say that the staff at the facility cannot access the enrollee's true mental health condition.The Plan denied your request. The Plan says the enrollee does not require a higher level of care.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 pre-approve the requested transportation. Our physician reviewer found that the enrollee has a history of paranoid schizophrenia,and developed delusions and suicidal ideation while in Brazil. She has been hospitalized in a psychiatric facility. She is treated with oral medication and is compliant with the medication regimen while hospitalized. There is no documentation of an accepting facility,and no documentation of a need for continued inpatient care. According to the treating physician records, she is stable to fly but would require a companion. There is no documentation that she would need to restrained chemically or physically during transportation. The documentation does not support that the enrollee suffers from an illness or injury that contraindicates transportation by any means other than ambulance. The documentation indicates that the enrollee is stable on current medications and can be transported by airplane with a companion.The documentation does not support that the enrollee's condition is such that the time needed to transport by ground, or the instability of transportation by ground, poses a threat to the enrollee's survival or seriously endangers her health. Therefore, the requested air ambulance service is not medically necessary.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve toilet and bathtub wall grab bars.
You asked the Plan to pre-approve grab bars. You say that these items are medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because grab bars are not primarily medical in nature and are not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve toilet and bathtub wall grab bars.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for a spinal canal injection. We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug.
You asked the Plan to reduce the cost-sharing charges for a spinal canal injection and Medicare Part B drugs. You say that you should only owe a specialist copayment. The Plan says that the claims were processed correctly and you are being charged the correct amount.
We decided that the Plan has to reduce the cost-sharing charges for a spinal canal injection from $95.41 to $45.
The plan contract says that you cannot be asked to pay more than a $45 copayment for specialist services. A spinal canal injection is considered surgical procedure. Therefore, you cannot be asked to pay more than a $45 copayment for the services. Therefore, we decided that the Plan has to reduce the cost-sharing charges for a spinal canal injection and Medicare Part B drugs from $95.51 to $45.
We also decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug.
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 20% coinsurance for Medicare Part B drugs. The allowed amount is $11.71 and 20% of that is $2.34. Therefore, we decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival irrigation (D4921) localized delivery of antimicrobial agents tooth 31 (D4381) unspecified diagnostic procedure (D0999) provided December 24, 2019 to December 26, 2019.
You asked the Plan to pay for the dental services. You say that you feel these services should be covered as part the of the scaling and root planing that you received. The Plan denied your request. The Plan says these services are not covered under the plan 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. 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 pay for gingival irrigation (D4921) localized delivery of antimicrobial agents tooth 31 (D4381) unspecified diagnostic procedure (D0999) provided December 24, 2019 to December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic counseling provided on December 19, 2019.
You asked the Plan to pay for genetic counseling. You say that you are appealing with medical records to support this charge. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this procedure code is not payable by Medicare so this claim should be re-submitted with a payable code.
The Plan must follow Medicare rules. Medicare rules say that procedure code S0265 is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic counseling have not been met. Therefore, we decided that the Plan does not have to pay for genetic counseling provided on December 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgical services provided from December 16, 2019 to December 17, 2019.
You asked the Plan to waive the coinsurance for outpatient surgical services. You say that you were not informed of the charges would be so high. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for surgery performed in an outpatient hospital facility. You received outpatient surgical services provided from December 16, 2019 to December 17, 2019. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $15,975.19 and 20% of that is $3,195.04. You have been asked to pay the total coinsurance amount of $3,195.04 for outpatient surgical services. Outpatient surgical services fall within the outpatient surgery, including services provided in hospital outpatient facilities and ambulatory surgical centers 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 coinsurance for outpatient surgical services provided from December 16, 2019 to December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the papsmear screening (Q0091), and the cervical or vaginal cancer screening; pelvic and clinical breast examination rendered by the out of network (OON) provider on January 24, 2020.You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment as you were unaware that this provider was not participating in the health plan's network.The Plan denied your request. The Plan says the services were provided 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the papsmear screening (Q0091), and the cervical or vaginal cancer screening; pelvic and clinical breast examination rendered by the out of network (OON) provider on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoes, inserts, and ankle foot orthoses provided on August 28, 2019.You asked the Plan to pay for the shoes, inserts, and ankle foot orthoses. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery to indicate that the specific items were delivered to the patient.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. There is no proof of delivery documentation in the file. Therefore, we decided that the Plan does not have to pay fo rthe shoes, inserts, and ankle foot orthoses provided on August 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the excess air ambulance mileage provided on October 15, 2019. You asked the Plan to pay for the excess mileage. You say that the ground ambulance did not show up so your physician called for the air ambulance. The Plan denied your request. The Plan says you chose to go to a specific hospital not the closest appropriate facility. 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 looked at the file and Medicare rules. The record shows you were transferred to your preferred hospital not the nearest one with appropriate facilities. Based on this information, we decided that Medicare rules for coverage of the excess mileage have not been met. Therefore, we decided that the Plan does not have to pay for the excess air ambulance mileage provided on October 15, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on September 4, 2019 to
September 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan
denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network
providers available for these services.
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 has network providers
available who can provide 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 physical therapy provided on September 4, 2019
to September 27, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on November 11, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
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 the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are 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 services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain.
She underwent an epidural steroid injection that provided two weeks of pain relief as well as trigger point
injection. The request is for RFA but there is no documentation of prior diagnostic medial branch blocks
(MBBs) that provided 80 percent or greater pain relief. The RFA is therefore not medically necessary at this
time.
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 radiofrequency ablation (RFA).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Chest X-ray 71045 provided January 16, 2020.
You asked the Plan to pay for the x-ray. You say that the patient had multiple exams on the same date. The Plan denied your request. The Plan says the claim was submitted as a duplicate.
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 code 71045 is not supported in the medical record. Specifically, the claim was submitted without a modifier to denote a repeat service. As submitted, the claim was a duplicate of a previously submitted claim. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a Chest X-ray 71045 provided January 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on July 1,2019.You asked the Plan to waive the copayment for the ambulance transport. You say that the hospital ordered the ambulance and you do not believe you should owe a charge for the ambulance. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transport falls within the "Ambulance Services" 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 the ambulance transportation provided on July 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 22, 2019 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 has network providers available who can provide 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 medical services provided on November 22, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitoring services rendered on August 19, 2019.
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 procedure codes 95909, 95886, and 95999 are not supported.
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 95909 is nerve conduction studies; 5-6 studies. The definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). The definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT codes 95909, 95886, and 95999 are not supported in the medical record. Specifically, there is no documentation of 5-6 nerve conduction studies to support code 95909. Given that the primary procedure code 95909 is not supported, the add-on code 95886 is also not supported. The documentation shows that Train of Four testing was performed, and 95999 is not the appropriate code for these services. 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 monitoring services rendered on August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive periodontal exam, teeth #1 and #32 (D0180) provided December 3, 2019.You asked the Plan to pay for the dental services. You say that please see attached documents, noting areas related to out of network care.The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.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 health plan contract says that services performed by an out of network dentist is not covered.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 pay for comprehensive periodontal exam, teeth #1 and #32 (D0180) provided December 3, 2019.