Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Therapy device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a high frequency chest wall oscillation device from a contracted provider can be approved.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no convincing evidence that the features of the Incourage device result in greater treatment success than other high frequency chest wall oscillation devices. The device could reasonably be provided by the in-network provider. While a high frequency chest wall oscillation device is considered medically necessary for the enrollee, it is not necessary for it to be from the out-of-network device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the  Therapy device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for Ambulance services (A0429, A0425)
provided January 7, 2020.
You asked the Plan to waive the deductible for the ambulance services. You say that the service should be
covered. The Plan denied your request. The Plan says the correct cost-sharing was 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 there is a $100 copayment after the deductible is met for Ambulance Services.
The item or service you asked the Plan to waive the deductible for falls within the benefit category Ambulance
Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $100
copayment after the deductible is met for Ambulance Services. The deductible was not met at the time services
were provided. The $364.95 charge was applied to the deductible. This cost sharing is a contractual obligation
that had not been met at the time the ambulance services was received on January 7, 2020. Therefore, we
decided that the Plan does not have to waive the deductible for Ambulance services (A0429, A0425) provided
January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunohistochemistry lab services provided on October 20, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says Code 88341 was billed without an appropriate primary procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 88341 is immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure). We find that CPT code 88341 is not supported. Code 88341 is an add-on code. The code at issue was not billed with a valid primary procedure code. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the immunohistochemistry lab services provided on October 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging procedure
(78452) provided on July 11, 2019.
You asked the Plan to waive the copayment for the myocardial perfusion imaging procedure. You say that you
are not sure why you are receiving a bill for this service. The Plan denied your request. The Plan says based on
Medicare billing criteria, the claim was billed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for nuclear medicine services.
You have been asked to pay $216.90 for the myocardial perfusion imaging procedure. 20% of $1,084.51 (the
allowed amount) equals $216.90. A myocardial perfusion imaging procedure falls within the nuclear medicine
services 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 myocardial perfusion
imaging procedure (78452) provided on July 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDap)
vaccine rendered to the enrollee on December 3, 2019.
You asked the Plan to pay for these services. You say that you needed the vaccine. The Plan denied your
request. The Plan says the vaccine is not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The
Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to these services.
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis
(TDap) vaccine rendered to the enrollee on December 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on November 14, 2019.
You asked the Plan to pay for the pump operation and assembly. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump operation and assembly have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on November 14, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 28, 2019 to
November 11, 2019 by an out of network (OON) provider.
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 were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The 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 October 28, 2019
to November 11, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for Ambulance services (A0425, A0428) provided January 7, 2020 by the provider.
You asked the Plan to waive the deductible for the ambulance services. You say that the ambulance transport should be covered. The Plan denied your request. The Plan says the deductible was not met at the time of service.
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 there is a $100 copayment after the deductible is met for Ambulance Services. The item or service you asked the Plan to waive the deductible for falls within the benefit category Ambulance Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $100 copayment after the deductible is met for Ambulance Services. At the time of service, the deductible was not met and the $229.48 cost was applied to your deductible. This cost sharing is a contractual obligation that had not been met at the time the ambulance services was received on January 7, 2020. Therefore, we decided that the Plan does not have to waive the deductible for Ambulance services (A0425, A0428) provided January 7, 2020 by the provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.
You asked the Plan to pre-approve Synvisc. You say that the medication is necessary to relieve the extreme pain you are experiencing. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that intraarticular knee injections of hyaluronan are covered when specific criteria is 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 Synvisc. Our reviewer says that the medication is not medically necessary. Our physician reviewer found based on the medical records provided you do not meet the coverage criteria as there has been no three month trial of treatment with analgesics and conservative non-pharmacological therapy (exercise or physical therapy, weight loss if appropriate, use of assistive devices). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided to the enrollee on August 8, 2019.
You asked the Plan to pay for the ambulance services. You say that stretcher transportation was deemed required to move the patient to their destination safely without causing more discomfort for the patient. The Plan denied your request. The Plan says that the ambulance transport to or from an outpatient office is not a Medicare 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 provided to the enrollee on August 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a screening mammography (77067) and screening digital
breast tomosynthesis (77063) provided on November 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the screening mammography and screening digital breast tomosynthesis. You say
that the claim should be paid. The Plan denied your request. The Plan says non-emergent services rendered by
non-participating providers in non-participating facilities require prior authorization, therefore coverage criteria
has not been met.
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 a screening mammography (77067) and screening
digital breast tomosynthesis (77063) provided on November 14, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit provided on December 20, 2019.
You asked the Plan to pay for the annual wellness visit. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says payment for the annual wellness visit received on December 20, 2019 was denied because you were previously seen for an annual wellness visit on March 27, 2019. The Plan says that your benefit maximum had been met for this service, and they are unable to adjust the claim for payment.
The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members the benefits offered under the plan including applicable conditions and limitations. We looked at the file, the Plan's contract and Medicare rules. Medicare rules say an annual wellness visit is covered once every 12 months. The file shows you received an annual wellness visit on March 27, 2019, which is less than 12 months from the annual wellness visit you received on December 20, 2019. Therefore, we decided that the Plan does not have to pay for the annual wellness visit provided on December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two battery packs.
You asked the Plan to pre-approve the packs. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare does not cover an extra set of batteries.
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 pre-approve two battery packs.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the hiatal hernia repair rendered to the enrollee on October 14, 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. The rules say that CMS does not pay for an "inpatient-only" service furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient hospital bill type (TOB 13X). We looked at the file and Medicare rules. The file shows that the provider billed code 43333 as outpatient. This code is an inpatient-only procedure and cannot be paid as outpatient. 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 hiatal hernia repair rendered to the enrollee on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 16, 2019 to the enrollee by a non-network provider. 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 were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 September 16, 2019 to the enrollee by a non-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transport (A0427)
and ground mileage (A0425) provided on December 11, 2019 by the ambulance service.
You asked the Plan to waive the copayment for emergency ambulance transport and ground mileage. You say
that you should not be responsible for the copayment since you were taken by ambulance without your consent
or without a clear understanding as to why transport by ambulance was necessary. The Plan denied your
request. The Plan says based on Medicare billing criteria, the claim was billed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for each ambulance service.
You have been asked to pay $250 for emergency ambulance transport and ground mileage. 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 emergency ambulance transport (A0427) and ground mileage
(A0425) provided on December 11, 2019 by by the ambulance service.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 14, 2019 tothe enrollee by a non-network provider.
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 were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The 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 October 14, 2019 to the enrollee by a non-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions of an erupted tooth or exposed root (D7140 x 7), the surgical extractions (D7210 x 4), and the alveoloplasty in conjunction with extractions (D7310 x 2) provided on September 24, 2019 by an out of network provider.
You asked the Plan to pay for the dental services. You say that you were referred to this dentist for the services you received by another dentist. You say that you were never told that the dentist office did not participate with your insurance. You say that this the dentist in this case is the only one that lives in your area. You also say that due to the nature of the state of your teeth, you had no choice but to continue with these services. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says the referring provider is not a network provider. The Plan also says dental services that you receive out of network are 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 dental services that you received are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the extractions of an erupted tooth or exposed root (D7140 x 7), the surgical extractions (D7210 x 4), and the alveoloplasty in conjunction with extractions (D7310 x 2) provided on September 24, 2019 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health.
You asked the Plan to pre-approve inpatient mental health. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 inpatient mental health. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of March 23, 2020 forward. The enrollee could have been treated in a lesser restrictive setting as they were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and were not showing any behaviors or aggression. The enrollee was being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive drug test billed for services provided to the enrollee on October 2, 2019.
You asked the Plan to pay for the presumptive testing. The Plan denied your request. The Plan says the billed test cannot be verified.
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 80307 is not supported in the records provided. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive drug test billed for services provided to the enrollee on October 2, 2019.