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

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you want to appeal the bill for the ambulance response services. The Plan denied your request. The Plan says these services are not a covered benefit.
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 October 11, 2019. 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 ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each (L5685) and all lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) (L5986) provided to the enrollee on October 30, 2019.
You asked the Plan to pay for the items. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the items have not been met. Healthcare Common Procedure Coding System (HCPCS) code L5685 - RT K2 (4 Units) remains not supported. The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. In addition, the documentation does not support the units billed. Therefore, the billed supply code and its units cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code L5986 - RT K2 (1 Unit) remains not supported. The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code L5301 - RT K2 (1 Unit) is supported by new documentation submitted with the appeal. Therefore, we decided that the Plan does not have to pay for addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each (L5685) and all lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) (L5986) provided to the enrollee on October 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair upgraded electronics.
You asked the Plan to pre-approve power wheelchair upgraded electronics. You say that the enrollee needs to
control the features with the joystick. The Plan denied your request. The Plan says the electronic upgrades
cannot be covered as it is not medically necessary to control the three approved power options through the
joystick (drive interface).
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Documentation shows that the enrollee has normal range of motion
and 4/5 strength in the right upper limb. Right upper limb strength and range of motion are adequate for the
enrollee to be able to control the power options using their own switches which are included in the allowance
of these power options. Based on this information, we decided that Medicare rules for coverage of power
wheelchair upgraded electronics. have not been met. Therefore, we decided that the Plan does not have to preapprove
power wheelchair upgraded electronics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services (CPT 98943) provided on January 6, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is not a covered benefit.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 chiropractic services (CPT 98943) provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal chiropractic manipulation (98943) provided on
January 8, 2020.
You asked the Plan to pay for extraspinal chiropractic manipulation. You say that this is allowed by CMS
guidance. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.
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 extraspinal chiropractic manipulation (98943) provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neurology evaluation and management services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON neurology services. You say that the patient has significant psychiatric disorder and traditional neurologist would not be prepared to handle the severity of disorder. You feel that only a provider with expertise in treating Huntington's is appropriate in this case. The Plan denied your request. The Plan says it was confirmed that the plan's network has a provider with experience treating Huntington's disease and other movement disorders. This provider is able to provide this care and his office is located 3.9 miles from the enrollee's home. Since there is no network deficiency, the OON services are not required.
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 the neurology evaluation and management services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete upper denture (D5110) and complete lower denture (D5120).You asked the Plan to pre-approvea complete upper denture and complete lower denture. You say that the requested dentures are necessary since your dentures were lost and you are not able to eat properly without them.The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria has not been met.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. The Plan covers one upper complete and one lower complete denture every five years.We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a complete upper denture and complete lower denture have not been met. The record shows that you received an upper denture and a lower denture on June 12, 2019. This means that you are not eligible for health plan coverage of a complete upper denture and a complete lower denture at this time.Therefore, we decided that the Plan does not have to pre-approvea complete upper denture (D5110) and complete lower denture (D5120).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services provided on November 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for mental health services. You say that the member presented symptoms meeting criteria for medical necessity. You would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 mental health services provided on November 11, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral to an out-of-network provider.You asked the Planto pre-approvethe referral. You say that it is medically necessary to have these services performed by an out-of-network provider.The Plandenied your request. The Plansaysthe same services can be performed by 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 Plandoes not haveto pre-approvea referral to an out-of-network provider.
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 you need incontinence supplies due to a medical condition.The Plan denied your request. The Plan says this item is not a covered benefit.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint (64625).
You asked the Plan to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint (64625). You say that the requested radiofrequency ablation, nerves innervating the sacroiliac joint is medically necessary. The Plan denied your request. The Plan says the requested radiofrequency ablation, nerves innervating the sacroiliac joint is not medically necessary.
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 radiofrequency ablation, nerves innervating the sacroiliac joint (64625). Our reviewer says that the requested radiofrequency ablation, nerves innervating the sacroiliac joint is not medically necessary. Our physician reviewer found the enrollee is with sacroiliitis refractory. The peer-reviewed medical literature is not supporting the requested procedure. SI Joint radiofrequency ablation for denervation whether performed using traditional, cooled, or pulsed radiofrequency is considered experimental and therefore, not medically reasonable and necessary. More research is needed to show safety and efficacy. There is not enough literature that has been published to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation, nerves innervating the sacroiliac joint (64625) have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint (64625).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (95819) provided on July 7, 2019.
You asked the Plan to pay for the electroencephalogram. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted did not
support the service billed.
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 95819 is electroencephalogram (EEG); including
recording awake and drowsy.
We asked our coder 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 electroencephalogram. Our reviewer says that CPT code
95819 does not meet criteria for billing or reimbursement consideration. Our reviewer found there was no
mention in the report that an electroencephalogram was recorded during both wake and sleep.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the electroencephalogram have not been met. Therefore, we decided that the
Plan does not have to pay for an electroencephalogram (95819) provided on July 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 16, 2020.
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says a benefit is payable when the primary insurance payer's calculated amount is less than the Medicare allowed rate for the service.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer.
The Plan has confirmed that payment made by the primary insurer was what would have been paid by Medicare. As the secondary insurer, the Plan cannot be held responsible for this visit as no further reimbursement is available under the Medicare payment guidelines. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision of hyperplastic tissue (D7140) and immediate upper denture with suction cups upgrade (D5130) provided October 21, 2019 to December 21, 2019.
You asked the Plan to pay for the dental services. You say that the provider has reported doing procedures on you that he did not do. He was not able to finish your dentures and refuses to pay you back the $1600 for the prepayment of dentures. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Services not listed are not covered by the plan. procedure code D7970 is not a listed service. The suction cups upgrade to the upper dentures are not covered as this was a personalization, characterization to a complete denture. 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 excision of hyperplastic tissue (D7140) and immediate upper denture with suction cups upgrade (D5130) provided October 21, 2019 to December 21, 2019.
Your complaint about the provider's treatment and abrupt behavior towards you is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia refill.
You asked the Plan to pre-approve Prolia refill. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee is not eligible for this refill yet.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Prolia refill. Our reviewer says that the documentation does not support that the requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has been receiving therapy with Prolia. The documentation indicates that the maximum dispensing limit for the drug is 1 syringe per 180 days. A review of pharmacy claims was performed and a recent paid claim was found for 1 syringe on January 3, 2020. The recent attempted fill is rejecting because it will result in a quantity greater than allowed in a 180 day time frame. This drug is available (covered) when dispensed as 1 syringe every 180 days. A recently attempted refill caused a computerized error code, stopping coverage. This is because the calculated amount appeared to be: either above the covered amount, or had an unusual dispensing interval. This medication was last dispensed on January 3, 2020. This drug is covered once every 180 days. The enrollee would be eligible for a refill on July 1, 2020. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia refill have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia refill.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 24, 2019. You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed. The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an UPWalker upright mobility walker.
You asked the Plan to pre-approve an UPWalker upright mobility walker. You say that you are hunched over from using a regular walker so you need an upright walker. The Plan denied your request. The Plan says the Durable Medical Equipment consulting evaluation reports an upright mobility walker is not safe for you.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The assessment shows an upright walker is not Medicare certified and not indicated for individuals who are a high fall risk. Based on this information, we decided that Medicare rules for coverage of an UPWalker upright mobility walker have not been met. Therefore, we decided that the Plan does not have to pre-approve an UPWalker upright mobility walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle-foot brace (AFO) provided on September 11, 2019.
You asked the Plan to pay for the AFO. You say that this claim is not for misrepresented services. The enrollee was contacted to ensure she still desired the brace she had ordered and no information was received that there was a failure in delivery. The Plan denied your request. The Plan says progress notes from the ordering physician were requested and not received. As such, the medical necessity of this brace cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that DME suppliers are required to submit documentation from the patient's medical records, if requested, in order to support that the items were medically necessary. Signed forms or physician attestations alone are not considered to be part of the record. In this case, the Plan requested progress notes from the ordering physician to confirm medical necessity. These were not submitted. Without this documentation, the medical necessity of this brace is not supported. Therefore, we decided that the Plan does not have to pay for the ankle-foot brace (AFO) provided on September 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan has to pre-approve phototherapeutic keratectomy.
You asked the Plan to pre-approve phototherapeutic keratectomy. You say that this is medically necessary. The
Plan denied your request. The Plan says that this was requested with an invalid code.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 phototherapeutic keratectomy. Our
reviewer says that the requested service is considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has a large corneal scar in the visual axis of the left eye that has caused a
decrease in uncorrected and best corrected visual acuity. Phototherapeutic keratectomy is medically reasonable
and necessary to help improve the patient's visual acuity. However, it cannot be billed with the requested code
and must instead be billed with a valid code.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of phototherapeutic keratectomy have been met. Therefore, we decided that the
Plan has to pre-approve phototherapeutic keratectomy.