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

We decided that the Plan does not have to waive the $50 copayment charged for ambulance transport provided
on December 18, 2019.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this copayment was charged based on the claim submitted by the
provider and the Plan contract agreement.
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 $50
copayment for ambulance transport. 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 $50 copayment charged for ambulance transport
provided on December 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran ultrasound (76770) provided July 10, 2019.You asked the Plan to pay forthe ultrasound. You say that the claim should be paid.The Plan denied your request. The Plan says the claim is a duplicate.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 76770 is not supported in the medical record. Specifically, the record shows a claim for the same service provided on the same date by the same provider was already paid on July 24, 2019. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met.Therefore, we decided that the Plan does not have to pay foran ultrasound (76770) provided July 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found based on review of available records, the enrollee does not meet criteria for coverage for an IRF admission. The enrolleeis generally medically stable after a gunshot wound and left upper extremity injury and there is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehabphysician three times per week or need for acute rehab nursing care.  Currently the enrolleeis at standby assistfor all mobility walking community distance.While the enrolleemay benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care.Based on review of the available records, the enrollee does not meet criteria for coverage for an admission to an IRF. Admission to an IRF is not medically necessary based on lack of medical complexity and functional status.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care provided on March 13, 2020 by an OON provider.You asked the Plan to pay forthe subsequent nursing facility care. You say that the treating physician depends on the hospital staff to verify eligibility and to obtain the proper authorization for in-network and out-of-network providers from the enrollee's insurance company. You also say that the services were medically necessary and provided in good faith.The Plan denied your request. The Plan says there is no evidence that the provider contacted the plan to verify insurance, current eligibility, or authorization requirements. The Plan also says that the provider failed to request prior authorization before rendering 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 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 forthe subsequent nursing facility care provided on March 13, 2020 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Human Leukocyte Antigen (HLA) typing and donor search for a stem cell transplant. You asked the Plan to pre-approve HLA typing and donor search for a stem cell transplant. 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 payment for these acquisition services is included in the MS-DRG payment for the allogeneic stem cell transplant when the transplant occurs in the inpatient setting and in the OPPS APC payment for the allogeneic stem cell transplant when the transplant occurs in the outpatient setting. We looked at the file and Medicare rules. Although this HLA typing may be appropriate, Medicare does not allow separate payment to be made for this type of testing related to a stem cell transplant. Based on this information, we decided that Medicare rules for coverage of HLA typing and donor search for a stem cell transplant have not been met. Therefore, we decided that the Plan does not have to pre-approve Human Leukocyte Antigen (HLA) typing and donor search for a stem cell transplant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the walking boot provided on March 29, 2020 by an in-network provider.
You asked the Plan to waive the cost-sharing for the DME. You say that the walking boot was ill fitting and not correct for your broken ankle. You state you could not wear it. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the walking boot on March 29, 2020 provided by an in-network provider. At the time of services rendered you had not met your $300 deductible; therefore, you have been asked to pay $186.12 for the services to apply to your deductible. You met your deductible with this DME and are asked to pay 20% coinsurance for the walking boot. 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 cost-sharing for the walking boot provided on March 29, 2020 by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
January 9, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a preventive
service and there should be no copayment. 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 specialist in-person office visit.
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows
this was not a preventive service.
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 specialist office visit provided on January 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that the items are necessary.The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence  supplies.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee had stable vitals. The enrollee required contact guard assistance with functional mobility including walking to 150 feet with a rolling walker. The enrollee required varying assistance with activities of daily living. The documentation does not support that the enrollee requires the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen and pelvis.
You asked the Plan to pre-approve the CT scan. You say that the records provided support the need for the
requested CT scan. The Plan denied your request. The Plan says the clinical information provided does not
show that a thorough workup failed to reveal the cause of weight loss and the requested CT scan is not
indicated at this time.
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 CT scan is not medically reasonable and necessary. Our physician reviewer found the subjective
report of weight loss is not objectively corroborated. Indeed, the enrollee gained weight over the preceding 2
months of observation. Evaluation by CT scan as requested for undocumented weight loss is not supported by
medical records as medically necessary for the indication requested.
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 the abdomen and pelvis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper and lower denture (D5110 & D5120)
provided on March 12, 2020.
You asked the Plan to pay for the complete upper and lower denture (D5110 & D5120). You say that you
believed the dental plan would cover $500 toward the denture replacement and half of the balance. You say
that dentures should be able to be replaced if they get worn or cracked. The Plan denied your request. The Plan
says the services are not covered benefits.
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. The records show your additional dental benefits were not active until
April 1, 2020. Therefore, we decided that the Plan does not have to pay for the complete upper and lower
denture (D5110 & D5120) provided on March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device and accessories for the enrollee.
You asked the Plan to pre-approve a power mobility device and accessories. You say that a power wheelchair
is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 a power mobility device and
accessories. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found based
on the medical records provided, the there is no indication the enrollee is unable to use a walker or manual
wheelchair inside the home. Medicare coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a power mobility device and accessories have not been met. Therefore, we
decided that the Plan does not have to pre-approve a power mobility device and accessories for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services received from an out-of-network provider on April 16, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the laboratory took your insurance card without asking any questions.
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 lab services received from an out-of-network provider on April 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 17,
2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says according to the claims data available at the time of the review, the plan was unable to discover
any evidence of an established relationship between the member and the ordering physician.
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 the denied codes is:
CPT 80307:
Drug test(s), presumptive, any number of drug classes, any number of devices orprocedures; by instrument
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS,RIA]),
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg,
DART,DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation
when performed,per date of service
HCPCS G0482:
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individualdrugs and
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to,
GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays
(e.g., IA, EIA, ELISA,EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope
or other universally recognizedinternal standards in all samples (e.g., to control for matrix effects, interferences
and variations in signal strength), and (3)method or drug-specific calibration and matrix-matched quality
control material (e.g., to control for instrument variationsand mass spectral drift); qualitative or quantitative, all
sources, includes specimen validity testing, per day; 15-21 drugclass(es), including metabolite(s) if performed
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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found the
records included an order form which was missing the enrollee's name, and the records provided did not
describe a relationship between the ordering physician and the enrollee or the context of the drug testing as
required to justify the codes submitted.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing services provided to the enrollee on July 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe radiology services provided on December 14, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe radiology services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.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 forthe radiology services provided on December 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 physician services provided to the enrollee from February 11, 2020 to March 3, 2020.You asked the Plan to pay for this service. You say that the Plan should cover these services for the enrollee.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 has network providers available who can provide 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 forphysician services provided to the enrollee from February 11, 2020 to March 3, 2020 by
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic chassis interface and custom silicone fabrication check socket described by two units of code L7699 for use with approved hand prostheses.You asked the Plan to pre-approve the prosthetic components described by L7699. You say that these units of L7699 must be approved as they are necessary for use with the prosthetics.The Plan denied your request. The Plan says it was found that the use of code L7699 for any component of a hand prosthesis is not allowed on initial issue as it is considered unbundling.The Plan must follow Medicare rules. The DME PDAC, the entity responsible for defining HCPCS codes, has indicated that use of L7699 on initial issue of a hand prosthesis is considered unbundling and is not appropriate.The file shows that this request is for the initial issuance of hand prostheses. As such, separate approval for code L7699 is not allowed.Therefore, we decided that the Plan does not have to pre-approve an electronic chassis interface and custom silicone fabrication check socket described by two units of code L7699 for use with approved hand prostheses.