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

We decided that the Plan does not have to pay for the ambulance services represented by code A0433 provided on April 18, 2021.
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. The rules say in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is pronounced dead by an individual authorized by the State to make such pronouncements.
We looked at the file and Medicare rules. In this case, the file shows that the enrollee's time of death pronouncement was after dispatch and before the enrollee was loaded onboard the ambulance. Medicare payment is based on the provider's/supplier's BLS base rate, no mileage or rural adjustment is reported, and the provider/supplier must use the QL modifier when submitting the claim. In this situation, the correct CPT code to bill is A0428 for non-emergency services after assessment. Therefore, we decided that the Plan does not have to pay for the ambulance services represented by code A0433 provided on April 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the denture repair provided on April 20, 2021.
You asked the Plan to pay for repair broken complete denture base, maxillary (D5512). You say that the materials and workmanship of your denture was inferior and did not last long. The Plan denied your request. The Plan says you have no coverage for repair of a broken denture base.
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. Your DEN856 dental plan benefit list does not include code D5512. Therefore, we decided that the Plan does not have to pay for the denture repair provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound debridement service (97597) rendered by the out-of-network (OON) provider on May 3, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for the wound debridement service
(97597) rendered by the out-of-network (OON) provider on May 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the purchased Inogen oxygen system provided on December 16, 2020.
You asked the Plan to pay for the purchased Inogen oxygen system. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the denial of payment for these items is correct because purchased oxygen equipment is not covered under Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage and purchased oxygen equipment is statutorily non-covered. We looked at the file and Medicare rules. Purchased oxygen equipment is not covered. Therefore, we decided that the Plan does not have to pay for the purchased Inogen oxygen system provided on December 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Barostim Neo device.

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 is on low doses of
guideline-directed congestive heart failure (CHF) medications and diuretics and is dyspnea is not well
quantified. There are no recent brain natriuretic peptide (BNP) results or recent hospitalizations for
decompensated CHF. The appeal letter also states that he has NYHA Class I symptoms, which does not meet
the FDA or published criteria for consideration of the Barostim Neo device. The documentation does not
support that the services are 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 Barostim Neo device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxygen concentrator and portable oxygen system and a non-invasive ventilator.
You asked the Plan to pre-approve oxygen concentrator and portable oxygen system and a non-invasive ventilator. You say that you doctor has recommended to have the machine at night to elevate bad gas and let oxygen in. The Plan denied your request. The Plan says the requested items are not medically necessary.
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. The rules also say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve oxygen concentrator and portable oxygen system and a non-invasive ventilator. Our reviewer says that the documentation does not support that the requested devices are medically reasonable or necessary. Our physician reviewer found your oxygen saturation level was at 92%. You were intubated for respiratory failure in March 2021. While you had been on home oxygen prior to the most recent hospitalization, the need for oxygen requires recertification. The records provided do not include oximetry or blood gas data that show a need for oxygen subsequent to hospital discharge. You may benefit from bilevel positive airway pressure (BiPAP) support during sleep. However, the records do not document CO2 retention. Medicare does not cover a home ventilator when used as BiPAP. There is no evidence of BiPAP failure while out of the hospital and stable, according to Medicare criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of oxygen concentrator and portable oxygen system and a non-invasive ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve oxygen concentrator and portable oxygen system and a non-invasive ventilator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 laboratory services provided on April 7, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307) rendered by the out-of-network (OON) provider on September 15, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug testing (80307) rendered by the out-of-network (OON) provider on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the precision attachments, by report (D5862) provided January 19, 2021.
You asked the Plan to pay for the precision attachments. You say that you purchased a dental rider because you were told implants were covered. The Plan denied your request. The Plan says that they checked phone call logs and did not find that any information regarding implants was provided at that time. This service is not covered under your 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 the precision attachments, by report (D5862) provided January 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care associated with an elective left hip arthroplasty.
You asked the Plan to pay for acute inpatient hospital care associated with a planned procedure. You say that you would like the inpatient stay approved. The Plan denied your request. The Plan says based on Medicare guidelines and the information they have about the enrollee's condition, the enrolle's care could be provided without an inpatient stay after the surgical procedure.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care associated with a planned procedure. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the review indicates that the enrollee is undergoing a planned left hip arthroplasty. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under code 27130 is not listed on the Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support that at the time of inpatient admission the admitting physician would reasonably expect that the enrollee's necessary hospital care would span two midnights We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care associated with a planned procedure. have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care associated with an elective left hip arthroplasty
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services provided on October 6, 2020 by an outof-
network (OON) provider.
You asked the Plan to pay for the OON services. You say that the enrollee was seen for a medical diagnosis.
The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and
authorization for certain 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 file shows that a computed tomographic (CT) angiography was provided. The provider in this case is not a
network provider with the Plan. The Plan had network providers available who could have provided 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 imaging services provided on October 6, 2020 by an out-of-network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) rendered on January 21, 2021.
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 claim has not been processed by the primary insurance.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed that an Explanation of Benefits (EOB) has not been received from the primary insurance. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) rendered on January 21, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diabetes supplies provided on December 3, 2020.
You asked the Plan to waive the coinsurance for the diabetes supplies. You say that you should not have a coinsurance because you have never had a coinsurance in the past. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 0% to 20% of the cost for Medicare-covered durable medical equipment. 0% coinsurance for items under $500 (Medicare approved) and 20% coinsurance for items $500 or more (Medicare approved).
You have been asked to pay 20% of the allowed amounts for the diabetes supplies. The diabetes supplies fall within the "Durable medical equipment (DME) and related supplies" benefit category. The record shows the allowed amounts were over $500 so the 20% coinsurance applies. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
December 3, 2020
Maintenance supplies for insulin infusion catheter
$591.90
20%
$118.38
December 3, 2020
Disposable sensor
$529.52
20%
$105.90
Total
$224.28
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 the diabetes supplies provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural steroid injections.

You asked the Plan to pre-approve lumbar injections. You say that you feel confident with this doctor. The Plan denied your request. The Plan says there are no symptoms of radiculopathy.

The Plan must follow Medicare rules. Medicare rules say that lumbar epidural injections are only covered under certain medical indications. 

We looked at the file and Medicare rules. The records provided do indicate that you previously received epidural injections. However, the records do not show a response to those injections to determine the value of repeating the procedure. Based on this information, we decided that Medicare rules for coverage of lumbar injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural steroid injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift chair provided on April 13, 2021.
You asked the Plan to pay for the provided chair. You say that you were told lift chairs were covered. The Plan denied your request. The Plan says the claim 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment.
The file shows that you received a seat lift mechanism. You have been asked to pay a 20% coinsurance for the device. The device falls within the durable medical equipment 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.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.
We looked at the file, and Medicare rules. Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide coverage only for items that Medicare covers. Based on this information, we decided that Medicare rules for coverage of the chair have not been met. Therefore, we decided that the Plan does not have to further pay for the seat lift chair provided on April 13, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing (G0483) provided on February 19, 2021.
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 that the records document only 14 tested drug classes.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is supported in the medical record. Specifically, the submitted medical records documented that more than 22 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for drug testing (G0483) provided on February 19, 2021.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve Euflexxa. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the criteria for coverage have been met in this case. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.