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

We decided that the Plan does not have to pay for the air ambulance services provided on April 4, 2020. 
 
You asked the Plan to pay for the air ambulance services. You say that these services were medically necessary 
and should be covered by the Plan. The Plan denied your request. The Plan says that your request is not 
medically necessary because your records show that you requested emergency air ambulance service to 
transport you from your vacation home to your son-in-law's home due to personal and family preference not 
medical necessity. 
 
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. The patient must be 
transported to the nearest hospital with appropriate facilities. 
 
The request for payment for the trip from Port Saint Joe, Florida to Court Miami, Florida is based on personal 
preference and convenience only. Based on this information, we decided that Medicare rules for coverage of 
the air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the 
air ambulance services provided on April 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 13, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you physician recommended you 
see another provider down the hall and you did not know you would owe a second copayment because the 
services were rendered on the same day within the same providers office. 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 a $20 
copayment for each specialist visit.  
 
You have been asked to pay a $20 copayment for each specialist visit. A 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 a specialist visit provided on February 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from 
September 18, 2018 to December 19, 2018 billed with code S9328. 
 
You asked the Plan to pay for the HIT services. You say that these services should be paid. The Plan denied 
your request. The Plan says the code used to bill for these services is not valid for Medicare purposes. 
 
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 S9328 is not supported. Specifically, this code has a status indicator of "I" in the 
Physician Fee Schedule, meaning that it is invalid for Medicare billing purposes. Based on this information, we 
decided that Medicare rules for coverage of the HIT services have not been met. Therefore, we decided that the 
Plan does not have to pay for the home infusion therapy (HIT) services provided from September 18, 2018 to 
December 19, 2018 billed with code S9328.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost shares for the medical services provided on April 8, 
2020. 
 
You asked the Plan to waive the cost shares for the services provided. You say that money is hard to come by. 
The Plan denied your request. The Plan says the claim was processed 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).  
 
You have been asked to pay a 20% coinsurance for the injection, and a $40 copay for the specialist office visit. 
The services fall within the Medicare Part B prescription drugs and physician services benefit categories. 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 cost shares for the medical services provided on April 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the power mobility device purchased on July 9, 2019.
You asked the Plan to reimburse you for the power mobility device. You say that the Plan should reimburse you for the PMD. The Plan denied your request. The Plan says the necessary evaluations were not completed for approval of the PMD.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that does not show you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair, or you can safely operate the PMD being requested. There is no face-to-face or home assessment documentation. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to reimburse you for the power mobility device purchased on July 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units of CT angiography (CPT 74174 and CPT 
74175) provided to the enrollee on February 28, 2020. 
 
You asked the Plan to pay for the additional units. You say that this should be paid for. The Plan denied your 
request. The Plan says the submitted documentation supports one unit each of CPT 714174 and 74175, which 
were previously approved and paid. 
 
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 74174: 
 
Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast 
images, if performed, and image postprocessing 
 
CPT 74175: 
 
Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if 
performed, and image postprocessing 
 
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 additional units. Our reviewer says that 
the additional units at issue in this case were not supported by the medical records. Our physician reviewer 
found a review of the records reveal a single record for the billed CPT 74174 and 71475. The amount paid on 
3/12/20 was $195.72 based upon Medicare allowable charges. There is no evidence of an additional charge on 
2/28/20 for a second payment. 
 
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 additional units have not been met. Therefore, we decided that the Plan does 
not have to pay for additional units of CT angiography (CPT 74174 and CPT 74175) provided to the enrollee 
on February 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehabilitation in order to get better. The Plan denied your request. The Plan says the records to not show that the enrollee meets the requirements for approval for an IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 the enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. Our reviewer also found that the enrollee may benefit from multiple therapies such as physical and occupational therapy, but the documentation does not support that the enrollee's functional status requires an intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve the Botox. You say that the enrollee has been receiving Botox injections 
every 3 months since August 12, 2019 for the treatment of blepharospasm and headaches. The enrollee has 
shown significant improvement in her symptoms from the treatment and this has improved the enrollee's 
physical and emotion state. The Plan denied your request. The Plan says since the medication will not be 
provided incidental to the physician visit, it is not covered under the medical benefit. The Plan says that the 
enrollee does not have a pharmacy benefit with them. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eyewear provided on March 17, 2020.
You asked the Plan to pay for the eyewear. You say that this should be paid by the Plan. The Plan denied your request. The Plan says that that they did not make a decision timely.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eyewear post cataract surgery with a $0 copayment. We looked at the file and the Plan's rules. The file indicates this eyewear was provided post cataract surgery. Based on this information, we decided that the Plan's rules for payment of the eyewear have been met. Therefore, we decided that the Plan has to pay for the eyewear provided on March 17, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on April 24, 2020.
You asked the Plan to pay for the office visit. 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 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 an office visit provided on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on March 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 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 medical services provided to you by an out-of-network provider on March 
9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need nurse assistance daily to build your 
endurance. You also say that inpatient admission will be the best option. The Plan denied your request. The 
Plan says the IRF services do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 you do not require the intensity of services provided at an IRF.  Specifically, you 
have not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  
Our reviewer also found that your care needs can be met at a lower level of care. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH admission is medically 
appropriate for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient acute care, and does not require a transfer to a LTACH. 
 
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 there is no evidence that the enrollee requires services that are not currently available.  
Our reviewer found that, as LTACHs and acute care hospitals are licensed to provide the same level of care, 
there is no advantage in transferring the enrollee to the LTACH.  Our physician reviewer also found that the 
enrollee can remain at the current acute care hospital until such time no acute services are required.  The 
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two additions of teeth to an existing partial denture 
provided on November 1, 2019. 
 
You asked the Plan to pay for the additions of teeth to an existing partial denture. You say that you had knee 
replacement surgery, which required you to receive dental clearance prior to the surgery. The Plan denied your 
request. The Plan says you had exceeded the limits set in the subscriber agreement. The Plan also says that the 
$1,000.00 benefit max was met before November 1, 2019. 
 
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 Plan offers a $1,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on October 21, 2019 and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the two additions of teeth to an existing partial denture provided 
on November 1, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on February 19, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 psychotherapy services provided on February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that there are no other facilities available that can take the enrollee, because the enrollee's condition is too advanced for a skilled nursing facility. The Plan denied your request. The Plan says the enrollee does not need to be seen by a doctor every day. The Plan also says that the enrollee can safely receive care in another setting, such as a skilled nursing facility.
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 enrollee does not require services at the LTACH that are not available at the current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that are not already being provided and covered at the current facility. Our physician reviewer also found that this request for LTACH services will be considered not medically necessary. The enrollee may be able to transfer to a lower level of care in the near future. 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 20, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior 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 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 an office visit provided on March 20, 2020 by an 
out of network (OON) provider.