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

We decided that the Plan does not have to pay for the radiologic examination, hand (73130) set-up portable xray
equipment (Q0092) transportation of portable x-ray equipment and personnel to home or nursing home
(R0070) provided on March 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the portable x-ray services. You say that please reconsider this claim and provide
payment at the current Medicare rate. The Plan denied your request. The Plan says enrollee's must receive their
medical services from an in-network provider with the exception being urgent or emergent services. Nonemergent
services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the radiologic examination, hand (73130) set-up
portable x-ray equipment (Q0092) transportation of portable x-ray equipment and personnel to home or nursing
home (R0070) provided on March 5, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthosis rendered on March 19, 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 provider is not Medicare-certified.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are
furnished by a provider or supplier enrolled in the Medicare program.
We looked at the file and Medicare rules. The provider is not Medicare-certified. Therefore, we decided that
the Plan does not have to pay for the orthosis rendered on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered on January 6, 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 procedure code 99053 is not separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is
always bundled into payment for other services not specified.

We looked at the file and Medicare rules. Billed procedure codes 99053 (service[s] provided between 10:00
PM and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and no separate
Medicare payment. Therefore, we decided that the Plan does not have to pay for the medical services rendered
on January 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device and garments provided on December 23, 2020.

You asked the Plan to pay for a pneumatic compression device (E0651) and garments (E0667). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation does not correlate with the Certificate of Medical Necessity that the enrollee has chronic venous insufficiency with ulcers.

The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of CVI with venous stasis ulcers. 

We looked at the file and Medicare rules. There is no record of CVI with venous stasis ulcers in the medical record. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device and garments provided on December 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627).
You asked the Plan to pre-approve the seat lift mechanism. You say that the mechanism is medically necessary.
The Plan denied your request. The Plan says coverage criteria has not been met.
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 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 seat lift mechanism. Our reviewer
says that the seat lift mechanism is not medically necessary. Our physician reviewer found the records do not
show objective imaging evidence of severe arthritis of the hip or knee or a severe neuromuscular disease. The
records do not show that a seat lift is included in the treating practitioner's course of treatment.
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 seat lift mechanism have not been met. Therefore, we decided that the Plan
does not have to pre-approve a seat lift mechanism (E0627).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says you are walking 60 feet twice and then 50 feet with a rolling walker. At this level of function, inpatient skilled nursing is not warranted as further services can be provided in a home setting.
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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care (ex. home, assisted living, long term 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from March 26, 2021, to April 9, 2021.

You asked the Plan to pay for chiropractic serves not related to manual manipulation of the spine. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says your provider billed services that are not related to manual manipulation of the spine, which are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. Medicare only covers manual manipulation of the spine. The services billed by your provider are ot related to manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from March 26, 2021, to April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87798, 87482) provided June 12, 2020.
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan denied your request. The Plan says urinary PCR testing is considered investigational and is not covered.
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 pay for the lab services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found urinary Polymerase Chain Reaction (PCR) testing raises considerable concerns regarding contamination from one specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results may also be challenging. Amplification of organisms representing latent infection or colonization cannot be distinguished from active, clinically significant infections. 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 lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87798, 87482) provided June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1812) with a heavy duty knee joint (L2385) and a knee control condylar pad (L2810) provided on February 1, 2021.
You asked the Plan to pay for a knee brace with a heavy duty knee joint and a knee control condylar pad. You say that the items at issue are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document provided as proof of delivery is not itemized nor does the document correspond to the provided itemized invoice. The provided document does not corroborate delivery of the items at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a knee brace (L1812) with a heavy duty knee joint (L2385) and a knee control condylar pad (L2810) provided on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital facility fee provided by a participating outpatient hospital facility on December 15, 2020.

You asked the Plan to waive the copayment for an outpatient hospital facility fee. You say that the visit that was provided does not warrant this high of a copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $325 copayment for outpatient hospital services/non-surgical visit. 

The enrollee has been asked to pay $129.47 which is less than your copayment amount of $325 for an outpatient hospital facility fee. The correct copayment has been applied to the services that were provided at an outpatient hospital facility. An outpatient hospital facility fee falls within the outpatient hospital services/non-surgical visit benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan.

This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient hospital facility fee provided by participating outpatient hospital facility on December 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport (A0427) provided on December 5, 2020.
You asked the Plan to pay for the ambulance service. You say that you got tired while out walking in your neighborhood and stopped to take a rest. You say that a neighbor was concerned and called 911. You say that you only remember one ambulance treating you and transporting you. You also say that you did not receive any information from this other ambulance company until you received the bill. The Plan denied your request. The Plan says there was no transport made. The Plan also says that ambulance services that do not include transport are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company in this case did not provide transport services on December 5, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. The file shows that the Plan paid the ambulance supplier that provided the transport. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport (A0427) provided on December 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pin retention (D2951) provided on April 14, 2021.
You asked the Plan to pay for the pin retention. You say that the pin retention was necessary to complete the
resin-based composite. The Plan denied your request. The Plan says this service is not covered.
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 pin
retention (D2951) provided on April 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on January 23, 2021.
You asked the Plan to pay for the ambulance response and treatment, no transport (A0998). You say that you called the fire department after a possible gas leak and you declined being transported because you felt perfectly well. You say that you should not be financially liable because you did not ask for the ambulance to come to your home. The Plan denied your request. The Plan says ambulance services performed without transport is a non-covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
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 ambulance response and treatment, no transport. Our reviewer says that ambulance response and treatment, no transport does not meet Medicare coverage criteria. Our physician reviewer found that CMS will pay for treatment in place in cases where the
individual that would have been transported would have met the Medicare criteria for a medically necessary
ground ambulance transport to the nearest appropriate facility that could have treated the enrollee's condition,
but such transport did not occur as a result of community-wide EMS protocols due to the Coronavirus
(COVID-19) public health emergency (PHE). The enrollee's condition must have required both the ambulance
transportation itself and the level of service provided in order for the billed service to be considered medically
necessary.
In this case, the record indicates that you contacted the utility company who then activated emergency medical
services (EMS). The record indicates that you were treated in place and you declined transportation. The record
does not indicate that transport did not occur as a result of community-wide EMS protocols due to the
Coronavirus (COVID-19) PHE. The elements of the coverage rule are not satisfied. The requested service
cannot be recommended.
The ambulance company did not provide transport services on January 23, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
(A0998) provided on January 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a quantity of 400 OneTouch Verio test strips per 33 days, for the enrollee.
You asked the Plan to pre-approve the test strips. You say that the strips are necessary. The Plan denied your request. The Plan says diabetic test strips have a quantity limit of 150 test strips per 30 days. The Plan states you requested coverage of a quantity of 400 test strips per 33 days. The Plan states they may be able to make an exception to the quantity limit; however, to make an exception, the enrollee's doctor must provide a supporting
statement showing the allowed quantity has not been effective or is not likely to be effective in treating the enrollee's condition. The Plan states there is no supporting statement to approve these.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the test strips have not been met. There is no supporting statement to approve these because the enrollee's doctor must provide a supporting statement showing the allowed quantity has not been effective or is not likely to be effective in treating the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve a quantity of 400 OneTouch Verio test strips per 33 days, for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gabapentin for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gabapentin for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for continuation of an inpatient stay provided from February 13, 2021, through February 15, 2021.
You asked the Plan to pay for the continuation of an inpatient stay. You say that the patient retained inpatient status for continued observation and management with the multi-disciplinary in-house staff and services. The Plan denied your request. The Plan says that continuation of the inpatient stay does not meet InterQual criteria.
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 pay for the continuation of an inpatient stay. Our reviewer says that continuation of the inpatient stay is considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee was admitted due to a worsening of a left heel ulcer after sustaining a fall five days prior. Following the evaluation, the enrollee was noted to have acute kidney injury as well as findings concerning for acute on chronic osteomyelitis. The record indicates that the Plan denied coverage of care from February 13, 2021, through February 15, 2021. The enrollee underwent surgery for external fixation and closure on February 10, 2021. Post-operatively the enrollee had evidence of acute kidney injury. The record indicates wound closure was performed but cultures were positive. The final culture results were necessary to tailor antibiotic coverage. The submitted records support that the stay from February 13, 2021, through February 15, 2021 was medically necessary and reasonable, as defined by Medicare rules. The elements of the coverage rule are satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of an inpatient stay have been met. Therefore, we decided that the Plan has to pay for continuation of an inpatient stay provided from February 13, 2021, through February 15, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 23, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on September 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an astigmatism-correcting intraocular lens (V2787) provided on January 4, 2021.
You asked the Plan to pay for an astigmatism-correcting intraocular lens. You say that you should be reimbursed because over the long haul the Plan would need to pay less to correct your astigmatism. The Plan denied your request. The Plan says rules for payment have not been met because the item at issue is not a Medicare or Plan benefit.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for an astigmatism-correcting intraocular lens (V2787) provided on January 4, 2021.