Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 29, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that this was for an annual wellness exam. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 physician services provided on October 29, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on August 5, 2020

You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with a correct place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The service at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on August 5, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0429) provided on July 12, 2020.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you only had one trip in the ambulance and should only have one copayment. The Plan denied your request. The Plan says you were given two separate ambulance rides by two different companies. Therefore, both copayments apply.

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 $300 copayment per one-way trip for ambulance services. 

You have been asked to pay a $300 copayment for each ambulance transportation service provided on July 12, 2020, for a total of $600. Documentation supports that you were transported in two separate ambulances by two different companies, therefore, two copayments apply. Ambulance transportation 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 services (A0429) provided on July 12, 2020/
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs HF System.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of congestive heart failure and has been hospitalized multiple times. The requested CardioMEMs system is considered experimental/investigational in nature, as the efficacy of the device remains uncertain. The services are therefore not reasonable or medically necessary. 

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 a CardioMEMs HF System.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal x-ray (72110) provided on August 5, 2020.

You asked the Plan to pay for the spinal x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 72110 is radiologic examination, spine, lumbosacral; minimum of 4 views. 

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 spinal x-ray. Our reviewer says that CPT code 72110 is not valid for billing or reimbursement consideration. Our coder found the medical records provided do include sufficient documentation of validate that a Radiologic examination, spine, lumbosacral; minimum of 4 views was performed on August 5, 2020, therefore, this service 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 the spinal x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the spinal x-ray (72110) provided on August 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the SNF admission. You say that you do not believe the enrollee can return home at this time due to her functional decline. The Plan denied your request. The Plan says no daily skilled needs are identified.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male with a history of stroke, who is currently in acute inpatient rehabilitation. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. Regarding rehabilitation services, the beneficiary received physical, occupational, and speech therapy in the acute hospital. The beneficiary was at a moderate to maximal assist with functional mobility. The beneficiary required varying assist with daily living activities. He tolerated a regular diet and nectar thickened liquids. 

There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, these do not require daily skilled therapy services. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Spravato nasal spray.

You asked the Plan to pre-approve Spravato nasal spray. You say that without continuation of this drug the enrollee is at risk for worsening symptoms. The Plan denied your request. The Plan says that the enrollee has not tried a third generic antidepressant for at least 12 weeks.

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 looked at the file and Medicare rules. The record shows this is a continuation request and the enrollee has been using this drug since October 6, 2020. Based on this information, we decided that Medicare rules for Step Therapy coverage of Spravato nasal spray have not been met. Therefore, we decided that the Plan has to pre-approve Spravato nasal spray.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 13, 2020, by an outof-
network (OON) provider.

You asked the Plan to pay for detoxification visit. You say that there was no time to request prior authorization
as this happened overnight, and you were under the impression that the Plan would cover this treatment. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider
is out-of-network with the Plan and authorization was not obtained.

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 medical services provided on August 13, 2020,
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transportation services provided to
the enrollee on September 24, 2020.

You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says non-emergent ambulance transportation services on date
of service September 24, 2020, from residence to physician's office and from physician's office to residence
denied as a non-covered benefit.

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 services have not been met. Ambulance services from the
residence to physician's office is a non-covered benefit per CMS guidelines. Additionally, medical records
provided indicates the enrollee was transported to the office for a routine office visit and the enrollee did not
have dialysis on this date of service. Therefore, we decided that the Plan does not have to pay for non-emergent
ambulance transportation services provided to the enrollee on September 24, 2020.
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 IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided you do not require the intensity of services provided at an IRF. Specifically, the medical records do not show that you require fifteen hours per week of rehabilitative services and regular physician evaluation. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest X-ray provided on October 3, 2020.

You asked the Plan to pay for the chest X-ray. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the service 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 a chest X-ray provided on October 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an otolaryngology (ENT) office visit provided on October 13, 2020.

You asked the Plan to waive the copayment for specialist visit. You say that you feel like this doctor did not do anything for you. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.


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 $35 copayment for specialist visit. 

You have been asked to pay $35 copayment for specialist visit. Specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 an otolaryngology (ENT) office visit provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on August 25, 2020.

You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services met coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. 

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) rapid flu test A and B (87804) provided on December 28, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that you are requesting reimbursement for the $209 paid for the flu shot. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 outpatient office visit (99203) rapid flu test A and B (87804) provided on December 28, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet rich plasma (PRP) injections (0232T).

You asked the Plan to pre-approve PRP injections. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that PRP injections are covered when specific criteria is 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 PRP injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found this is an experimental/investigational procedure. There are no studies showing efficacy in post-laminectomy syndrome. The procedure is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PRP injections have not been met. Therefore, we decided that the Plan does not have to pre-approve platelet rich plasma (PRP) injections (0232T).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the denial is consistent with Medicare benefit.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve in-home cleaning and laundry services.

You asked the Plan to pre-approve the cleaning and laundry services. You say that you do not feel that the services should be denied. The Plan denied your request. The Plan says this is not a Medicare-covered benefit.

The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. 

The services requested are considered custodial care as they do not involve the services of trained medical or paramedical staff. Therefore, we decided that the Plan does not have to pre-approve in-home cleaning and laundry services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat and a shower chair.

You asked the Plan to pre-approve the equipment. You say that the enrollee requires the equipment. The Plan denied your request. The Plan says these items are not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats and shower chairs are not covered because they are not primarily medical in nature. 

While a raised toilet seat may be appropriate for G. Sanchez Nadal, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat and a shower chair.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre=approve additional routine transportation trips for the 2021 calendar year.

You asked the Plan to pre=approve the additional trips. You say that you need to have more trips approved because once they are used up, you will have no way to get to dialysis, as well as your other medical appointments. The Plan denied your request. The Plan says the benefit for routine transportation cannot be extended.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 40 trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you will exhaust the Plan maximum benefit for coverage of routine transportation after your 40th trip. There is no provision in the contract which would require the Plan to extend this benefit. Therefore, we decided that the Plan does not have to pre=approve additional routine transportation trips for the 2021 calendar year.