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

We decided that the Plan has to pay forthe foot orthotics provided on March 5, 2020.You asked the Plan to pay forthe foot orthotics. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that prior authorization was not obtained.The Plan follows Medicare rules. The rules say if a network physician furnishes a service to a MA beneficiary for a plan-covered service without following the plan's internal procedures (such as obtaining the appropriate plan pre-authorization), then the beneficiary should not be penalized to the extent the physician did not follow plan rules. According to Medicare rules, you should not be penalized because a plan contracted provider did not follow prior authorization rules of the health plan.Therefore, we decided that the Plan has to pay forthe foot orthotics provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe rest home visit (99336) provided on October 7, 2020, by an out-of-network (OON) provider.You asked the Plan to pay foran OON rest home visit. You say that this should be covered.The Plan denied your request. The Plan says this was not authorized.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 providerwith the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe rest home visit (99336) provided on October 7, 2020, by an out-of-network (OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided.

You asked the Plan to pay for the ambulance services. You say that the ambulance services provided was medically necessary.The Plan denied your request. The Plan says the ambulance services provided was not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ambulance services. Our reviewer says that the ambulance services provided on was not medically necessary. Our physician reviewer found per the reviewed documentation, upon ambulance arrival, emergency medical services reported that the enrollee was sitting on the floor with a chief complaint of left knee and back pain. The member's husband stated "She has had this pain for a long time, becoming more and more immobile due to the chronic pain, and needs a surgery but hasn't been able to get it due to COVID". The enrollee was hemodynamically stable with stable vital signs.

The review has determined that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The documentation did not support that the ambulance transport was medically reasonable and necessary for the enrollee.

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 ambulance services have not been met.Therefore, we decided that the Plan does not have to pay for the ambulance services provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on September 15, 2020, to September 30, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you were told that these services would be covered.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the physician who provided these services is not in-network with this specific 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forphysician services provided on September 15, 2020, to September 30, 2020 by an out of network (OON) provider
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay foran emergency room visit (99281) provided August 25, 2020.You asked the Plan to pay forthe emergency room visit. You say that the service was medically necessary.The Plan denied your request. The Plan says a correct claim is needed.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 99281 is not supported in the medical record. Specifically, an invalid revenue code was used for this Type of Bill. Based on this information, we decided that Medicare rules for coverage of the emergency room visit have not been met.Therefore, we decided that the Plan does not have to pay foran emergency room visit (99281) provided August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99214) provided on July 1, 2020.You asked the Plan to pay forthe office visit. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not pre-authorized. There were network providers available.Medicare rules say that plans can require enrollees to get carefrom network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services 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 these services.Therefore, we decided that the Plan does not have to pay foran office visit (99214) provided on July 1, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe LINX reflux management procedure.You asked the Plan to pre-approvethe procedure. You say that this is medically necessary.The Plan denied your request. The Plan says this is not considered reasonable and necessary under Medicare guidelines.The Plan must follow Medicare rules. Medicare rules say that the LINX device is considered medically reasonable or necessary by Medicare.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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found coverage is not available for LINX Reflux Management System, which is not a true endoluminal treatment but is also not considered reasonable and necessary for your condition. The safety and efficacy of the LINX device is unproven in the setting of Barrett's esophagus. Your history of dysphagia is a relative contraindication to the LINX 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 procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvethe LINX reflux management procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), endodontic therapy (D3310), local anesthesia (D9215), and consultation (D9310) provided on September 9, 2020.You asked the Plan to pay forthe intraoral periapical x-rays, endodontic therapy, local anesthesia, and consultation. You say that you contacted the Plan and were given the name of the provider. You also say that you do not understand why these services were not covered.The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also said that you had not purchased an additional dental rider.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 thatthe Plan does not have to pay forthe first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), endodontic therapy (D3310), local anesthesia (D9215), and consultation (D9310) provided on September 9, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvefacet joint injections for the enrollee.You asked the Planto pre-approvethe injections. You say that this is medically necessary.The Plandenied your request. The Plansaysthe pain is not mostly localized to the low back.The Plan must follow Medicare rules. Medicare rules say that facet joint injections cannot be covered for radicular pain.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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has radiculopathy. The enrollee does not meet the criteria for this request.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 injections have not been met.Therefore, we decided that the Plandoes not haveto pre-approvefacet joint injections for the enrollee
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychotherapy services (90832) provided on August 21, 2020.You asked the Plan to pay forthe psychotherapy services. You say that you would like reconsideration because this service was billed correctly.The Plan denied your request. The Plan says this claim was not billed with the appropriate place of service code.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 90832 is not supported in the record. Specifically, the record does not indicate that the member was in a Part A Skilled Nursing Facility stay. This claim was billed with a place of service code which would indicate the Part A stay. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met.Therefore, we decided that the Plan does not have to pay forthe psychotherapy services (90832) provided on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe manipulative treatment provided on September 15, 2020.You asked the Plan to pay forthe chiropractic office visit provided on September 8, 2020. You say that you were misinformed about coverage.The Plan denied your request. The Plan says the office visit is not a covered service.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 forthe manipulative treatment provided on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally forthe dental services with dental codes D0120, D0220, D0230, and D4910 provided on August 4, 2020.You asked the Plan to pay additionally fordental codes D0120, D0220, D0230, and D4910. You say that you would like the Plan to reconsider your request.The Plan denied your request. The Plan says the dental claims processed correctly.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.We looked at the file, the Plan's contract and Medicare rules. The file shows the provider billed service D0120 in the amount of $61. The allowed amount for the service is $19. The Plan pays 100% of the allowable amount per the benefits outlined in the Evidence of Coverage (EOC). The Plan paid $19. You are responsible forall fees billed by the provider in excess of the allowed amount $42 ($61-$19). Your liability for dental code D0120 is $42.The file shows the provider billed service D0220 in the amount of $35. The Plan pays 100% of the allowable amount per the benefitsoutlined in the EOC. The Plan paid $11. You are responsible for all fees billed by the provider in excess of the allowed amount $24 ($35-$11). Your liability for dental code D0220 is $24.The file shows the provider billed service D0230 x 2 in the amountof $35 each. The Plan pays 100% of the allowable amount per the benefits outlined in the EOC. The Plan paid $8 for each unit. You are responsible for all fees billed by the provider in excess of the allowed amount $27 for each unit ($35-$8). Your liability for dental code D0230 x 2 is $54.
The file shows the provider billed service D4910 in the amount of $160. The Plan pays 100% of the allowable amount per the benefits outlined in the EOC. The Plan paid $58. You are responsible for all fees billed by the provider in excess of the allowed amount $102 ($160-$58). Your liability for dental code D4910 is $102.Therefore, we decided that the Plan does not have to pay additionally forthe dental services with dental codes D0120, D0220, D0230, and D4910 provided on August 4, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on February 24, 2020 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that you would like this appeal reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the rendering facility is also out-of-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We foundno exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forskilled nursing services provided on February 24, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora stress test (93017) provided October 2, 2020.You asked the Plan to waive the copayment forthe stress test. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for advanced imaging services. You have been asked to pay a $150 copayment for the stress test. The stress test falls within the advanced imaging services benefit category. This means that youhave 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 fora stress test (93017) provided October 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that without orthotics you have exceptional pain every step with both feet.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe urgent care visit provided on August 4, 2020.You asked the Plan to reduce the copayment forthe urgent care visit. You say that you were told by your primary care doctor to go to urgent care. You say you went to urgent care thinking it would be the same copayment as a PCP visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $40 copayment for each covered office visit to other providers for urgently needed services. You have been asked to pay a $40 copayment for the urgent carevisit. The urgent care visit falls within the "Urgently needed services" benefit category. The record shows you were seen at an urgent care center.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 reduce the copayment forthe urgent care visit provided on August 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from July 1, 2020 to July 28, 2020.You asked the Plan to pay forhome health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this claim was not billed with an appropriate HIPPS code.The Planmust 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, this claim has been submitted with an invalid HIPPS code.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from July 1, 2020 to July 28, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approverepairs to a ceiling patient lift from a provider not enrolled in Medicare.You asked the Plan to pre-approvethe services. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says services rendered by a provider not enrolled in Medicare are not covered.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.Medicare will only cover your durable medical equipment (DME) if your doctors and DME supplies are enrolled in Medicare. The provider you are requesting to perform repairs to your ceiling patient lift is not enrolled in Medicare.Therefore, we decided that the Plan does not have to pre-approverepairs to a ceiling patient lift from a provider not enrolled in Medicare
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe oxygen concentrator provided on January 30, 2020 to February 29, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe oxygen equipment. You say that the records prove medical necessity.The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain 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 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 hasnetwork providers available who could have provided the items at issue in this appeal.The Plan did not pre-approve the itemat issue. We found no exception that would require the Plan to pay for these items.Therefore, we decided that the Plan does not have to pay forthe oxygen concentrator provided on January 30, 2020 to February 29,2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCT, lumbar spine; without contrast material (CPT Code 72131).You asked the Plan to pre-approvethe CT Scan. You say that the CT scan is necessary.The Plan denied your request. The Plan says there is no documented need for both studies for pre-surgical planning.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 physician reviewer found there is not documentation supporting whya CT scan would need to be done on the same area of the body without contrast as a non-contrasted MRI. Due to lack of indication in the documentation the denial is upheld.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-approveCT, lumbar spine; without contrast material (CPT Code 72131)