Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the limited oral evaluation (D0140) provided on December 18, 2019. 
 
You asked the Plan to pay for the dental service. You say that you cancelled your previous dental plan, effective June 31, 2019, as you had moved. You say that the previous plan allowed 2 dental visits per year, one of which you used in April 2019. You say that you opened an entirely new and separate policy which also allows for 2 dental visits per year. You say that you used 1 visit in October 2019. You say that you confirmed with the Plan that you would be able to receive one more covered visit for the year. You also say that had you known it would not have been covered, you would have waited until after the first of the year. The Plan denied your request. The Plan says that the frequency limit has been exceeded. 
 
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 Plan covers the dental service when the services are medically necessary and reasonable. 
 
We looked at the file and Medicare rules. The record shows that you became active with the new plan effective August 1, 2019. The Evidence of Coverage for Plan ID H0028 clearly states that the dental benefit covers 2 oral exams per calendar year. The record also shows that the new plan paid for 1 oral exam that you received on October 24, 2019. Based on this information, we decided that the H0028 Plan's coverage limit of 2 oral exams has not been exhausted. Therefore, we decided that the Plan has to pay for the limited oral evaluation (D0140) provided on December 18, 2019.  
 
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 the assembly and operation of a heart/lung machine and related lab services provided on September 25, 2019 during an inpatient stay.
You asked the Plan to pay for the heart/lung machine operation and lab testing. You say that this was medically necessary care and should be paid to the provider. The Plan denied your request. The Plan says payment for these services has been included in the DRG payment made to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare rules say all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. Although these services may be appropriate, since they are non-physician services, payment for them is made to the hospital which must then furnish these services either directly or under arrangements. As such, separate Medicare payment cannot be made for the services at issue. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a heart/lung machine and related lab services provided on September 25, 2019 during an inpatient stay.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to D. Burnett Sr on September 30, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to D. Burnett Sr on September 30, 2019.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria. 
 
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care from a SNF on 03/09/20 for a urinary tract infection (UTI) and shortness of breath. She had a right cerebella and medullar stroke with residual right hemiparesis in February 2020 also resulting in respiratory failure status post tracheostomy and dysphagia. 
 
The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive IRF physician or nursing supervision. The enrollee may benefit and participate from multiple therapies such as physical therapy and occupational therapy, however the documentation does not support that this enrollee can tolerate or fully participate in 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered from April 2, 2019 to June 25, 2019.You asked the Plan to payforthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claims were not billed correctly.The Plan must follow Medicare rules. The rules say that a treatment authorization code is required for home health claims.We looked at the file and Medicare rules. The claims were not billed with the required treatment authorization code. 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 forthe home health services rendered from April 2, 2019 to June 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency ablation of the knee.
You asked the Plan to pre-approve the ablation. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental and investigational.
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 ablation. Our reviewer says that the requested ablation is not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental and investigational procedure that is the subject of on-going clinical trials. Therefore, the request is considered 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 the ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular radiofrequency ablation of the knee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genecept testing. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this type of testing is considered experimental and investigational. 
 
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 testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence to support that the requested service is medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Genecept testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 24, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you were told that you would
only owe a $10 copayment and disagree with the additional charges. 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 $45
copayment for each visit with a specialist.
You have been asked to pay a $45 copayment for a 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 September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 25, 2019.
You asked the Plan to pay for the 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 stating exactly what tests are to be performed.
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 for the drug testing services provided on September 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you live on the second floor of your building and cannot go up and down the stairs alone due to your extreme pain. Your building does not have an elevator and even though you can now navigate the stairs because of physical therapy, you still need someone to accompany you. You say that you need the ambulance transport in order to have someone to help you. 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 for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on October 31, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency 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 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 forthe medical services provided to the enrollee by an out-of-network provider on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).
You asked the Plan to pre-approve a home ventilator (E0466). You say that the requested home ventilator is medically necessary. The Plan denied your request. The Plan says the requested home ventilator is not medically necessary.
The Plan must follow Medicare rules. The rules 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 a home ventilator (E0466). Our reviewer says that the requested home ventilator is not medically necessary. Our physician reviewer found the enrollee is with a history of chronic obstructive pulmonary disease (COPD). Coverage criteria for a home ventilator are not met. This enrollee has COPD with chronic hypercarbic respiratory failure. BiPAP support at night may be indicated. A home ventilator is not medically necessary. There is no documentation of BiPAP failure while the enrollee is in a stable state, i.e., persistent hypoxemia or worsening pCO2 while on BiPAP and appropriate supplemental oxygen. Certain BiPAP devices are capable of providing the AVAPS-AE mode of support, and Medicare does not cover ventilators when used as BiPAP. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator (E0466) have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe device evaluations (93298 and 93299) provided on March 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forOON device evaluations. You say that these services were medically necessary.The Plan denied your request. The Plan says these 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 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 forthe device evaluations (93298 and 93299) provided on March 4, 2019 by an out of network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on November 5, 2019. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. 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 hospital outpatient clinic visit provided on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a 3D CT scan and transvaginal ultrasound provided by the physician on November 6, 201 
 
You asked the Plan to waive the copayments for a 3D CT scan and transvaginal ultrasound. You say that you were told that the visit was free. 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 $180 copayment for advanced imaging services provided at a specialist's office.  
 
You have been asked to pay $78.01, which is less than the $180 copayment for a 3D CT scan and transvaginal ultrasound. A 3D CT scan and transvaginal ultrasound fall within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for a 3D CT scan and transvaginal ultrasound provided by the physician on November 6, 201
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain
management infusion; administrative services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (S9328) provided to the enrollee from December 18, 2018 to February 12,
2019.
You asked the Plan to pay for these services. You say that this was medically necessary for the enrollee. The
Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that home infusion services and supplies may be covered
as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan
does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
You are billing for home infusion services S9328. This is not a valid code for Medicare purposes and the plan
does not offer an additional benefit for this service. Therefore, we decided that the Plan does not have to pay
for the home infusion therapy, implanted pump pain management infusion; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided
to the enrollee from December 18, 2018 to February 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for electric wheelchair lift
You asked the Plan to pay for the electric wheelchair lift. You say that you were told that the lift was covered
because you cant use the chair unless you can take it with you. You took out a loan and you need your money
back because your money is limited. The Plan denied your request. The Plan says this item is considered a
convenience item and does not meet the definition of durable medical equipment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for electric wheelchair lift.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
October 27, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that this should be covered
because it was a medical emergency. The Plan denied your request. The Plan says the copayment is your
financial responsibility.
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 $200
copayment per one-way ambulance trip.
You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls
within the one-way ambulance trip 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 transport provided on October 27, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve trigger point injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no evidence of conservative therapy.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the injections. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has failed conservative therapy. Therefore, the request is medically reasonable and 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 the injections have been met. Therefore, we decided that the Plan has to pre-approve trigger point injections for the enrollee.