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

We decided that the Plan does not have to pay for the ambulance transport provided by an out-of-network provider on October 13, 2020.
You asked the Plan to pay for the ambulance transport. You say that the enrollee has been in a wheelchair and has MS. You say that this was an emergency and should be covered. The Plan denied your request. The Plan says prior authorization is required for non-emergency transport.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. The records show that a non-emergency transport was billed. 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 ambulance transport provided by an out-of-network provider on October 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from September 7, 2020, to September 11, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code G0156 (140 unit) remains not supported. The documentation submitted did not include notes or time documentation. The billed service 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 codes and the required documentation. In this case, the records provided do not support the services billed. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from September 7, 2020, to September 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider
from August 7, 2020, through August 28, 2020.
You asked the Plan to pay for physical therapy. You say that you were advised you could be seen by anyone at
the clinic, and it would be covered. You say that if you had known it would not be covered you would not have
taken the treatment. The Plan denied your request. The Plan says you must receive care from a network
provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
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 physical therapy provided by an out-of-network
provider from August 7, 2020, through August 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on October 26, 2020.
You asked the Plan to pay for the diagnostic radiology services. You say that the enrollee is bed bound and the services had to be performed "STAT" and you had no time to obtain authorization. The Plan denied your request. The Plan says the service was performed by a non-contracted supplier which require authorization and there is not one on file.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the radiology services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for diagnostic radiology services provided on October 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (20939).
You asked the Plan to pre-approve bone marrow aspiration. You say that the requested service is medically
necessary. The Plan denied your request. The Plan says rules for pre-approval have not been met because the
requested service 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 bone marrow aspiration. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that bone marrow aspirate remains experimental for use in spinal fusion surgery.
More research is needed to show safety and efficacy of bone marrow aspirate. Iliac crest autograft is the gold
standard graft material.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan
does not have to pre-approve bone marrow aspiration for bone grafting (20939).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a sleep study. You say that you would like the Plan to approve these services for the member. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 a sleep study to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services of home health/hospice aide in home health or hospice settings (G0156) provided from July 13, 2020, to July 18, 2020.
You asked the Plan to pay for the services of home health/hospice aide. The Plan denied your request. The Plan says the documentation submitted did not include documentation of note and time was not documented. The Plan also says that this provider is not Medicare certified.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services of home health/hospice aide have not been met. Therefore, we decided that the Plan does not have to pay for the services of home health/hospice aide in home health or hospice settings (G0156) provided from July 13, 2020, to July 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (D9430) provided on November 25, 2020.
You asked the Plan to pay for an office visit. You say that you would like the Plan to pay for the service. The
Plan denied your request. The Plan says this service is not a covered 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.
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 an office
visit (D9430) provided on November 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 additional physical therapy visits.
You asked the Plan to pre-approve physical therapy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for additional physical therapy is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the therapy that the enrollee has been receiving is generally accepted as specific and effective therapy for the enrollee's condition. However, the records do not support that the continued services of a professional therapist are required to safely and effectively provide treatment 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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 additional physical therapy visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for integrated biopsychosocial assessment provided on
August 27, 2020.
You asked the Plan to pay for the integrated biopsychosocial assessment. The Plan denied your request. The Plan says services are available with Plan providers.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for integrated biopsychosocial assessment provided on August 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits to be provided by an out-of-network provider.
You asked the Plan to pre-approve additional physical therapy visits. You say that treatments from an in-network provider have not been successful. You say your out-of-network referral was approved so you are not sure why this is denied. The Plan denied your request. The Plan says 3 additional visits for a total of 18 were approved. The Plan also says that any additional visits thereafter will need to be received from an in-network provider.
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 additional physical therapy visits to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis (J7322).
You asked the Plan to pre-approve Hymovis. You say that the enrollee needs Hymovis. The Plan denied your request. The Plan says the enrollee does meet medical necessity criteria for viscosupplement injections. The Plan says that the request for Hymovis, specifically, is not necessary. The Plan says that Hymovis is a non-preferred drug. The Plan also says that the enrollee has not tried any of the preferred drugs.
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 Hymovis. Our reviewer says that Hymovis is not medically necessary. Our physician reviewer found the documentation provided does not show that the enrollee has tried and failed the preferred drugs. The reviewer found that the provided there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that Hymovis is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have
to pre-approve Hymovis (J7322).
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the ultrasound. We decided that the Plan does not
have to waive the copayment for the CT scan.
You asked the Plan to waive the copayment for the ultrasound and CT scan. You say that there is no
coinsurance, copayment or deductible for a preventive screening. You say that you do not agree with the
copayments. The Plan says that the copayments applied correctly.
We decided that the Plan has to waive the copayment for the ultrasound.
The records do not show a diagnostic indication for the ultrasound. The records show that an abdominal aorta
aneurysm screening was performed and billed. The Evidence of Coverage clearly states there is no cost for this
preventive screening. Therefore, we decided that the Plan has to waive the copayment for the ultrasound.
We also decided that the Plan does not have to waive the copayment for the CT scan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $200
copayment for CT, MRI, MRA, and SPECT scans. The CT scan is considered diagnostic imaging. Therefore,
we decided that the Plan does not have to waive the copayment for the CT scan.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care.

You asked the Plan to pay for inpatient care. You say that according to Medicare there were 60 inpatient days available so this claim should qualify for payment. The Plan denied your request. The Plan says the denial of payment for this inpatient stay is correct, because the inpatient hospital care benefit period had been exhausted for this stay.

The Plan must follow Medicare rules. Medicare rules say that inpatient hospital care is covered for up to 90 days per benefit period. The Plan also covers 60 lifetime reserve days for inpatient hospital care.

We looked at the file and Medicare rules. This benefit period previously had 438 days of inpatient hospital care applied to it. Therefore, at the time of this inpatient stay both the 90 days of covered inpatient care per benefit period and the 60 lifetime reserve days had been exhausted. Based on this information, we decided that Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on September 18, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you were unaware there was a copayment. The Plan denied your request. The Plan says the copayment applied 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 $90 copayment for each hospital emergency room visit. You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show you were treated in the ER. 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 ER visit provided on September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says only services directly related to manual manipulation of the spine are covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses.

You asked the Plan to pay for the eyeglasses. You say that you would like some portion paid for the eyeglasses. The Plan denied your request. The Plan says you are responsible for any amount above the coverage limit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The records show that the Plan paid for the routine eye exam, including refraction, with no cost share for you. The records also show that the Plan paid $85 for the provided eyeglasses, which allowed you to reach your benefit maximum. Therefore, we decided that the Plan does not have to further pay for the eyeglasses.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the nuclear medicine study with CT imaging skull base to mid-thigh, measurement of glucose in blood using reagent strip, and Fluorodeoxyglucose provided on July 15, 2020.
You asked the Plan to pay for the nuclear medicine study, glucose measurement, and Fluorodeoxyglucose. You say that these services should be covered. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 8, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the nuclear medicine study with CT imaging skull base to mid-thigh, measurement of glucose in blood using reagent strip, and Fluorodeoxyglucose provided on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for other medicine services and procedures, chronic care management (9199) provided February 3, 2020 to August 3, 2020
You asked the Plan to pay for the chronic care management. You say that the description of services should have been chronic care management, which is covered under Medicare Plan B. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for other medicine services and procedures, chronic care management (9199) provided February 3, 2020 to August 3, 2020.