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

We decided that the Plan does not have to pre-approve additional non-emergent transportation trips.
You asked the Plan to pre-approve additional routine transportation. You say that you would like additional routine transportation to be covered. The Plan denied your request. The Plan says the maximum 50 trips have already been covered and additional routine transportation is not eligible for coverage.
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 50 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 have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergent transportation trips
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that any other level of care is not sufficient to optimize the enrollee's ability to improve. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or therapy services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our physician reviewer found that the most recent therapy documentation indicates the enrollee has decreased activity tolerance and is unable to ambulate. She requires hands on assistance for bed mobility and transfers. She does not have any parenteral medication, complex wound care, or nutrition given via a feeding tube. The documentation indicates that she is at her recent, post-covid infection baseline. She does not require skilled nursing or skilled therapy services on a daily basis. Therefore, a SNF admission is not 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance angiography (MRA) of the abdomen and pelvis.
You asked the Plan to pre-approve the MRAs. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that an MRI of the abdomen/pelvis is medically and necessary for the indications established in the applicable LCD. 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 MRAs. Our reviewer says that the requested MRAs are medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a history of both cerebral aneurysms and fibromuscular dysplasia. As such, there is reason enough to suspect renal artery stenosis based on fibromuscular dysplasia as well as a reasonable suspicion for visceral aneurysms considering the enrollee's other aneurysms and fibromuscular dysplasia. Additionally, as fibromuscular dysplasia can involve the iliac arteries, imaging through the pelvis is also both 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 MRAs have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance angiography (MRA) of the abdomen and pelvis.
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: Testing
Decision: Favorable

We decided that the Plan has to reduce the copayment for the transthoracic echocardiography represented by
code C8929 provided on March 30, 2021.
You asked the Plan to reduce the copayment for code C8929. You say that you feel that the copayment is
incorrect, and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says
that the correct copayment has applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay $50 for each Medicare-covered standard x-ray and
ultrasound.
The Plan says you must pay a $250 copayment for code C8929. Based on the Plan contract, however, you
cannot be asked to pay more than $50 for code C8929. The file shows that you received a transthoracic
echocardiography. This test is an ultrasound of the heart. Therefore, we decided that the Plan has to reduce the
copayment for the transthoracic echocardiography represented by code C8929 provided on March 30, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on January 5, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that CPT codes describing anesthesia services (00100-01999) or services that are bundled into anesthesia should not be reported in addition to the surgical or medical procedure requiring the anesthesia services if performed by the same physician. We looked at the file and Medicare rules. Billed procedure code 99199 is not the appropriate code for anesthesia services billed by an anesthesia practitioner. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on January 5, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan services provided on June 1, 2020 by an out-of-
network (OON) provider.
You asked the Plan to pay for the duplex scan services provided by an OON provider. 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 duplex scan services provided on June 1, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diabetic shoes provided on March 17, 2021.
You asked the Plan to waive the coinsurance for the diabetic shoes. You say that you were told there would be no additional cost for the shoes. 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 20% coinsurance for diabetic supplies and therapeutic shoes.
You have been asked to pay $65.82 which is 20% of the allowed amount for the diabetic shoes. The allowed amount is $329.18. ($329.18 x 20% = $65.82). The diabetic shoes fall within the "Diabetic self-management training, diabetic 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 coinsurance for the diabetic shoes provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete denture- maxillary (CPT code D5110) and complete denture mandibular (CPT code D5120).
You asked the Plan to pre-approve the dental services. You say that this is an emergency because you have been without teeth for eleven (11) weeks and it is stopping you from eating properly. The Plan denied your request. The Plan says you exhausted your benefit.
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. Review of the file show that you received complete denture- maxillary (CPT code D5110) and complete denture mandibular (CPT code D5120) on June 3, 2021. Additionally, on June 3, 2021, you went for a fitting for the dentures made by another provider and you were scheduled to pick them up on June 23, 2021, however, you did not show up to that appointment. Moreover, the office of dentist you originally saw on June 3, 2021, is
willing to assist with the issues you are currently having with your dentures. Your 2021 EOC states complete dentures (upper and lower) (One (1) upper complete and one lower complete denture every five (5) years, including routine post-delivery care) or Partial dentures (upper and lower) (One upper and/or one lower partial denture every five years, including routine post-delivery care)Includes necessary extractions to fit dentures (unlimited). Therefore, we decided that the Plan does not have to pre-approve complete denture- maxillary (CPT code D5110) and complete denture mandibular (CPT code D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete denture- maxillary (CPT code D5110) and complete denture mandibular (CPT code D5120).
You asked the Plan to pre-approve the dental services. You say that your teeth previously made did not fit and do not stay in your mouth. The Plan denied your request. The Plan says you exhausted your benefit.
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. Review of the file show that you received complete denture- maxillary (CPT code D5110) and complete denture mandibular (CPT code D5120) on October 26, 2020. Your benefits have been exhausted for the 2021 plan year. Your 2021 EOC states complete dentures (upper and lower) (One (1) upper complete and one lower complete denture every five (5) years, including routine post-delivery care) or Partial dentures (upper and lower) (One upper and/or one lower partial denture every five years, including routine post-delivery
care)Includes necessary extractions to fit dentures (unlimited). Therefore, we decided that the Plan does not
have to pre-approve complete denture- maxillary (CPT code D5110) and complete denture mandibular (CPT
code D5120)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is experimental/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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex Superion spacer remains experimental. More research is needed to show safety and efficacy.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on February 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. 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 physician services provided on February 25, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy services.
You asked the Plan to pre-approve massage therapy services. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says massage therapy is not covered by
Medicare or the Plan.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore,
we decided that the Plan does not have to pre-approve massage therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.
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 you do not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered
for enrollees weighing 350 to 600 pounds.
We looked at the file and Medicare rules. The records show that you do not weigh at least 350 pounds to 600
pounds. 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 heavy duty extra wide hospital bed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an outof-
network (OON) provider.
You asked the Plan to pre-approve the physical therapy services to be provided by an OON provider. You say
that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the
requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are innetwork
providers available to you that can provide the care and treatment you are requesting.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (CPT code 99203) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the office visit. You say that due to your condition from cervical spinal cord compression you were strongly advised to be cautious when traveling by car. The Plan denied your request. The Plan says this provider is out-of-network and the services were not urgent or emergent.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The provider at issue in this case is not a network provider with the Plan. 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 office visit. Our physician reviewer found there is no documentation that care with out-of-network provider was/is medically necessary as opposed to care with an in-network provider. There is nothing in the records which documents that an in-network provider could not provide
adequate care for your 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 office visit have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the office visit. Therefore, we decided that the Plan does not have to pre-approve the office visit (CPT code 99203) to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cataract surgery (66984) provided on
April 8, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $550
copayment for outpatient surgery rendered by an in-network provider.
You have been asked to pay a $550 copayment for the outpatient surgery provided. 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 cataract surgery (66984) provided on
April 8, 2021.
Your complaint that you were assessed a copayment for a surgery that was not completed is not a valid appeal
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare
does not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services billed with code A0429 provided on March 9, 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 payable 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 billed with code A0429 provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be rendered by the OON provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the service at issue in this appeal. We found no exception that would require the
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office
visit to be rendered by the OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 28, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 87506 is not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. We looked at the file and Medicare rules. Billed procedure code 87506 (infectious agent detection) has a status indicator of X and is excluded from Medicare payment. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 28, 2020.