Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and the routine venipuncture (36415) rendered by the out-of-network (OON) provider on February 16, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the office visit (99214) and the routine venipuncture (36415) rendered by the out-of-network (OON) provider on February 16, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to provide acute inpatient hospital care.
You asked the Plan to provide acute inpatient hospital care. You say that the enrollee is still being treated for medical issues. The Plan denied your request. The Plan says that the services needed can be provided in an observation level of care.
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 provide acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the member is still in the inpatient setting. The records show that at the time of inpatient admission the admitting physician reasonably expects that the patient's necessary hospital care (including earlier 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 been met. Therefore, we decided that the Plan has to provide acute inpatient hospital care.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified ambulance service (A0999) provided on March 29, 2021.
You asked the Plan to pay for the ambulance service. You say that you were not aware that treat and release with an ambulance was not a covered service with Medicare. You say that you would have gone to the hospital if you had been aware of that detail. You also say that you feel you should not have to pay the full amount. The Plan denied your request. The Plan says ambulance services are only payable when you are transported to a hospital.
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 March 29, 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 the unspecified ambulance service (A0999) provided on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services.
You asked the Plan to pre-approve chiropractic services. You say that this treatment is medically necessary. The Plan denied your request. The Plan says chiropractic maintenance care is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. Based on the records provided, the services requested are maintenance care. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient hospital care to be provided for Left Total Knee Replacement after care.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the enrollee can be safely taken care of in an observation setting.
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 that the enrollee is medically stable, and a total knee arthroplasty (knee replacement surgery) is not listed as an inpatient procedure. The enrollee may be safely taken care of in an observation setting. There is no documentation provided necessitating inpatient level of care services. The enrollee can be safely taken care of after the surgery in an observation setting. The record does not show that the admitting physician reasonably expected that the enrollee's necessary hospital care after a Left Total Knee Replacement 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 acute inpatient hospital care to be provided for Left Total Knee Replacement after care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial denture (D5820) provided on September 28, 2020.
You asked the Plan to pay for the interim partial denture (D5820). You say that your provider called for authorization before the work was done and you were not informed it was not covered. You say that you want help with this claim. The Plan denied your request. The Plan says a temporary denture is not covered by the Plan.
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 interim partial denture (D5820) provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on April 21, 2021.
You asked the Plan to pay for the first intraoral periapical x-ray. You say that your dentist told you the periapical x-rays were done because there are no teeth in your upper arch. You also say that since bitewing x-rays would not have been appropriate you believe an exception should be made for the intraoral x-ray. 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 first intraoral periapical x-ray (D0220) provided on April 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of abdomen 74170.
You asked the Plan to pre-approve the CT scan. You say that you had kidney cancer 5 years ago and the cancer was removed. It's time for a yearly check-up and you have to get a CT scan to make sure it is not coming back. The Plan denied your request. The Plan says the records do not support the Medicare criteria for the requested service.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 pre-approve the CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records indicate that the enrollee has had no evidence of recurrence since 2014 and has not had any new symptoms/signs of recurrence. The medical records provided do not meet the requirements listed in the LCD for Medicare coverage. As such, the requested study is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of abdomen 74170.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular services and pharmaceutical blend provided on November 25, 2020.
You asked the Plan to pay for the services provided. You say that medical records support the medical necessity of the services. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services.
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 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The CPT Code Manual definition of code 97112 is Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. We find that the CPT code are not supported in the medical record. The records do not include a plan of care for electrical stimulation on the date of service at issue. The records do not indicate neuromuscular reeducation was provided.
The records show that a nutria-pharmaceutical blend was injected on the date of service at issue. Procedures should be reported with the most comprehensive code. The blend should not be unbundled. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular services and pharmaceutical blend provided on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedures provided on March 31, 2021.
You asked the Plan to pay for the unspecified removable prosthodontic procedures. You say that you were not happy with the dentures, so you returned to have them remade. You say that you aren't going to pay another dime. The Plan denied your request. The Plan says the 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 the unspecified removable prosthodontic procedures provided on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for sneakers provided on March 26, 2020.
You asked the Plan to reimburse you for the sneakers. You say that shoes are your primary source of exercise for running and should be covered. The Plan denied your request. The Plan says running sneakers are not a covered item for the Wellness Allowance benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
The Plan's rules for coverage of gym benefits have not been met because sneakers are not a covered benefit. Therefore, we decided that the Plan does not have to reimburse you for sneakers provided on March 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308 x 2) provided from September 2, 2020, to September 4, 2020.
You asked the Plan to pay for the evaluation and management services. You say that the services should be covered. The Plan denied your request. The Plan says the provider in this case is not certified with Medicare. The Plan also says that payment cannot be made for services performed by a provider that is not certified with Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99308 x 2) provided from September 2, 2020, to September 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided to the enrollee on April 19, 2021.
You asked the Plan to pay for this claim. You say that this equipment should be covered by the Plan. The Plan
denied your request. The Plan says the records provided do not show a direct relationship between the enrollee
and the listed ordering physician.
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 establish a relationship between the listed ordering provider and the enrollee. 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 foot orthotics provided to the enrollee on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (G0480) rendered by the out-of-network (OON) provider on December 8, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug testing (G0480) rendered by the out-of-network (OON) provider on December 8, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on July 2, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the hospital services were medically necessary. The Plan denied your request. The Plan says you were discharged from the emergency department on July 2, 2021 on oral antibiotics with outpatient follow up care. The hospital record does not indicate admission to the hospital was ordered.
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 that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the necessary hospital care (including earlier emergency department 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 on July 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 12, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that when you contacted the Plan you were advised that you have a $1,000 allowance for dental services and believe this should be covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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 problem focused limited oral evaluation (D0140) provided on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear provided on March 4, 2021. 
 
You asked the Plan to pay for the eyewear. You say that you are entitled, under the Plan vision coverage, for 
the Plan to pay for the eyewear. The Plan denied your request. The Plan says the Plan paid for eyewear 
provided on July 16, 2019 in the amount of $125. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every 24 months. We looked at the file and the Plan's rules. The file shows that the Plan paid for eyewear provided to you on  
July 16, 2019. Since the eyewear benefit is covered every 24 months, you have exceeded the maximum Plan 
benefit. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been 
met. Therefore, we decided that the Plan does not have to pay for eyewear provided on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiomyopathy risk factor screening panel testing provided 
on October 26, 2020. You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies 
coverage for all cardiovascular risk assessment panels for patients with suspected or documented 
cardiovascular disease. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover 
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for cardiomyopathy 
risk factor screening panel testing provided on October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra battery for portable oxygen concentrator.
You asked the Plan to pre-approve an extra battery for portable oxygen concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says separately billed options, accessories or supply items will be denied as unbundling.
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 would be considered a convenience item since it is not required for the item to function correctly. Therefore, we decided that the Plan does not have to pre-approve an extra battery for portable oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 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 the Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.