Persius/hicric huggingface dataset:
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 on the date of service you suffered a hypoglycemic attack which required immediate response and treatment. You say that once the responders arrived, they immediately treated you and brought your blood glucose back to appropriate levels. You recovered quickly and after checking your vitals and conferring with a Doctor, you stated that the EMS responders released you without requiring hospitalization. You say that you believe the services should be covered by the Plan. 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 does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 26, 2019. 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 the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings and resin-based composite provided on January 9, 2020 by an OON provider.
You asked the Plan to pay for the bitewings and resin-based composite. You say that your dentist told you that they were in the Plan's network. You also say that you would like the Plan to pay for this dental bill because the provider believed they were in the Plan's network and you thought they were too. The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that there is no prior authorization on file.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the bitewings and resin-based composite provided on January 9, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on November 14, 2019.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no evidence of a trial and failure of Retacrit.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of
a trial and failure of Retacrit. The documentation does not support that Retacrit would likely be less effective,
and/or would likely have adverse effects for the enrollee in this case.
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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Procrit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an upright walker purchased on January 9, 2020 from a non-contracted vendor.
You asked the Plan to pay for the walker. You say that you are requesting reimbursement of the walker you purchased. The Plan denied your request. The Plan says this provider is not contracted with the Plan or Medicare.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an upright walker purchased on January 9, 2020 from a non-contracted vendor.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement of nails (11720) provided on November 19, 2019.You asked the Plan to pay for the debridement. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the record does not support that the billed service is separate from the service that has been processed and paid.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 11720 is not supported in the record. Specifically, the documentation submitted does not include record of the date of service at issue. Without this documentation, we are unable to verify that CPT code 11720 is a separately billable service from the service which has been processed and paid. Based on this information, we decided that Medicare rules for coverage of the debridement have not been met.Therefore, we decided that the Plan does not have to pay for debridement of nails (11720) provided on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for tumor treatment field therapy provided on January 18, 2020.You asked the Plan to pay for tumor treatment field therapy (E0766). You say that this is the best FDA approved option at this time for treatment.The Plan denied your request. The Plan says this service is not reasonable and necessary for the treatment of recurrent GBM.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 tumor treatment field therapy (E0766). Our reviewer says that the services were not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has histologically confirmed (World Health Organization (WHO) grade IV astrocytoma), newlydiagnosed, supratentorial GBM. The beneficiary has received initial treatment with maximal debulkingsurgery (when feasible), followed by chemotherapy and radiotherapy. Tumor treatment field therapy is initiated within 7 weeks from the last dose of concomitant chemotherapy or radiotherapy, whichever is later; and the beneficiary has no evidence of progression by Response Assessment in Neuro-Oncology (RANO) criteria. Continuation is not approved as tried and failed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tumor treatment field therapy (E0766) have not been met.Therefore, we decided that the Plan does not have to pay for tumor treatment field therapy provided on January 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair with additions.You asked the Plan to pre-approve power mobility device. You say that you are not able to get around without use of a wheelchair.The Plan denied your request. The Plan says the denial of authorization for this item is correct, because you have not been evaluated for a power wheelchair and thus there is no doctor's written order, home evaluation, 7-element order for a power wheelchair, evaluation that this device meets your needs, and evaluation of your ability to safely utilize this device.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage for any item, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Medicare rules say that a group 2 power wheelchair is only covered after the enrollee has had a specialty evaluation and the ordering provider has completed a standard written order for the item.We looked at the file and Medicare rules. No medical records were submitted with this case. The Plan attempted to obtain medical records however none were received by the Plan. Without medical records, we cannot determine that you meet all necessary Medicare coverage criteria for the requested power mobility device. Based on this information, we decided that Medicare rules for coverage of power mobility device have not been met.Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair with additions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on February 5, 2020.You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on February 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from November 1, 2019 to November 5, 2019.You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the required Q code, FIPS, CBSA and values were not billed on the submitted claim.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include the required FIPS and Q codes.Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from November 1, 2019 to November 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ezetimibe.You asked the Plan to pre-approve Ezetimibe. You say that you would like reconsideration as this drug is medically necessary for the treatment of the member's condition.The Plan denied your request. The Plan says this drug is not covered for the member's condition under Medicare 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 Ezetimibe.Benefits for Ezetimibe 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve outpatient office visits and oral surgical splints.
You asked the Plan to pre-approve the outpatient office visits and oral surgical splints. You say that your dentist said you would benefit from injections and two mouth guards. The Plan denied your request. The Plan says that you do not appear to meet criteria for the appliance and the requested appliance appears to be excluded from Medicare coverage benefit.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 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 outpatient office visits and oral surgical splints. Our reviewer says that the service is meets coverage criteria. Our physician reviewer found this treatment is for a condition (TMJ Dysfunction Syndrome) which is medical in nature and does not involve the treatment of dental complex (teeth and supporting structures). Our reviewer found that as a result of the examination, a diagnosis of arthralgia and osteoarthritis of the TMJ was made. Our physician reviewer also found that the treatment proposed is aimed at this 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 outpatient office visits and oral surgical splints have been met. Therefore, we decided that the Plan has to pre-approve outpatient office visits and oral surgical splints.
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 medical services provided on December 19, 2019 by an out of network (OON) provider.You asked the Plan to pay for laboratory tests. You say that you were not aware of the requirement to obtain prior authorization and the referring provider deemed the services to be medically necessary.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite - three surfaces, anterior (D2332) and resin-based composite - two surfaces, posterior (D2392) provided on January 6, 2020.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.
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 records show that you exceeded your $200 allowance for fillings on January 6, 2020. Therefore, we decided that the Plan does not have to pay for resin-based composite - three surfaces, anterior (D2332) and resin-based composite - two surfaces, posterior (D2392) provided on January 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 15, 2019 through July 17, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation 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 have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 15, 2019 through July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision care services provided on January 13, 2020 by an out-of-network provider.
You asked the Plan to pay for vision care services. You say that you thought you were completely covered in your plan. The Plan denied your request. The Plan says you do not have out-of-network benefits.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for vision care services provided on January 13, 2020 by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided from October 12, 2019 to October 13, 2019 by an out of network provider.
You asked the Plan to pay for the laboratory services. You say that the claim has not been paid in full or under the terms of the contract for the services that were rendered to the enrollee. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services provided from October 12, 2019 to October 13, 2019 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says it's preferred viscosupplements are Orthovisc and Monovisc, and they don't require prior authorization.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of the required drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Synvisc injection for the enrollee.