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

We decided that the Plan does not have to pay for the ambulance services provided on October 31, 2020.

You asked the Plan to pay for the ambulance 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 31, 2020. 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 provided on October 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee cannot tolerate intensive therapy.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care.

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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the co-payment for the ultrasound provided on November 23,
2020.

You asked the Plan to reduce the co-payment for the ultrasound. You say that you want to know why you are
being charged more for a co-payment when the cost is lower than the year before. You say that your co-payment
should be the same as last year. The Plan denied your request. The Plan says the co-payment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110
co-payment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a free-standing facility (such as a radiology center or medical clinic).

You have been asked to pay a $110 co-payment for the ultrasound. The ultrasound falls within the "Outpatient
Diagnostic Tests and Therapeutic Services and Supplies" benefit category. 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 co-payment for the ultrasound provided on November 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on July 17, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is covered when specific criteria are met.

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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee had elevated prostate specific antigen (PSA) and underwent a prostate biopsy on June 18, 2020 notable for benign prostatic tissue. The records do not support that the enrollee was being considered for a repeat prostate biopsy due to persistent or elevated cancer-risk factors. The ConfirmMDx testing was not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing rendered on July 17, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (CPT code 90837) provided to the enrollee from June 9, 2020, through August 25, 2020, by a non-participating provider.

You asked the Plan to pay for the psychotherapy services. You say that the plan paid for the services previously. The Plan denied your request. The Plan says the enrollee self-directed out-of-network 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 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. Furthermore, review of the previous claims shows that the plan did not pay you for your services due to the same reason. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (CPT code 90837) provided to the enrollee from June 9, 2020, through August 25, 2020, by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance (CPT code
E0673) and PCD (CPT Code E0675) provided to the enrollee on December 9, 2020.

You asked the Plan to pay for the DME. You say that the enrollee's physician ordered the DME to prevent the
enrollee from developing deep vein thrombosis, or blood clots as well as pulmonary embolism. The Plan
denied your request. The Plan says the enrollee used the equipment in the facility during and/or after surgery.
The Plan states that payment for this service would have been included under the facility claim. The Plan states
payment for this service is the responsibility of the facility or hospital that provided the surgery.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.

Records show that the DME was used in a SNF or hospital. Furthermore, a PCD is not covered by Medicare to
prevent deep vein thrombosis during and/or following surgery. Therefore, we decided that the Plan does not
have to pay for segmental gradient pressure pneumatic appliance (CPT code E0673) and PCD (CPT Code
E0675) provided to the enrollee on December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gas and lodging compensation from February 20, 2020, to
September 15, 2020.

You asked the Plan to pay for gas and lodging compensation pertaining to your ankle surgery. You say that
since the Plan does not have an ankle surgeon in your area the Plan should at least pay your extra expenses.
The Plan denied your request. The Plan says they do not cover travel and lodging services for this procedure,
and they have providers within 100 miles that could have treated you.

The Plan must follow Medicare rules. Medicare rules say that an MA plan must provide reasonable
transportation and accommodations for transplant services at a more distant location.

We looked at the file and Medicare rules. This service was not a transplant procedure. Based on this
information, we decided that Medicare rules for coverage of gas and lodging compensation have not been met.
Therefore, we decided that the Plan does not have to pay for gas and lodging compensation from February 20,
2020, to September 15, 2020.
Appeal type: Transportation
Decision: Unfavorable


We decided that the Plan does not have to waive the co-payment for the ambulance transport provided on
December 14, 2020.

You asked the Plan to waive the co-payment for the ambulance transport. You say that the bill should be
checked, and corrections made as necessary. The Plan denied your request. The Plan says the co-payment
applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275
co-payment for each one-way Medicare-covered ground trip.

You have been asked to pay a $275 co-payment for the ambulance transport. The ambulance transport falls
within the "Ambulance Services" benefit category. 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 co-payment for
the ambulance transport provided on December 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for CT scan of abdomen and pelvis before and after contrast (CPT code 74178) provided on December 21, 2020.

You asked the Plan to waive the co-payment for the CT scan. You say that your cost share should be $45 for diagnostic procedures and test, not $250. The Plan denied your request. The Plan says you called the Health Plan prior to the date of service, December 21, 2020, inquiring about a CT Scan, and you were advised CT scans have a $250 co-payment.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance).

Review of the file show that you had a CT scan of abdomen and pelvis before and after contrast on December 21, 2020. You were asked to pay a $250 co-payment for the CT scan. Your 2020 EOC states that enrollees must pay a $250 co-payment for CT scans. 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 co-payment for CT scan of abdomen and pelvis before and after contrast (CPT code 74178) provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99223) provided on November 18, 2020.

You asked the Plan to pay for hospital care. You say that this was medically necessary. The Plan denied your request. The Plan says this was billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that physicians/practitioners who furnish services to a hospital outpatient, including in a hospital outpatient department (including in a provider-based department of that hospital) or under arrangement to a hospital shall, at a minimum, report the off campus-outpatient hospital Place of Service (POS) code 19 or on campus-outpatient hospital POS code 22 irrespective of the setting where the patient actually receives the face-to-face encounter. 

We looked at the file and Medicare rules. The service at issue was billed with POS 21, inpatient hospital, but the records show that the enrollee was a hospital outpatient on this date of service. Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99223) provided on November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a biopsy of soft oral tissue (D7286) provided on November
16, 2020.

You asked the Plan to pay for a biopsy of soft oral tissue. You say that you did not know this service would not
be covered. The Plan denied your request. The Plan says the service at issue 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 a biopsy
of soft oral tissue (D7286) provided on November 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power tilt/recline system, head rest, and expandable controller with harness and electronic connection for a Group 3 power wheelchair (PWC).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the power tilt/recline system is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a power/tilt recline system is covered when specific criteria are met. The rules say that an expandable controller and harness with electronic connection is covered to operate multiple power options.

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 these services. Our reviewer says that the power tilt/recline system is not medically necessary. Our physician reviewer found the enrollee does not use a ventilator mounted to a wheelchair and does not meet the coverage criteria for a power tilt and power recline seating system. There is no evidence of intermittent catheterization, spasticity, or evidence of being high risk for a pressure ulcer. The power tilt/recline system is therefore not reasonable or medically necessary.

The file shows that the requested expandable controller with harness and electronic connection are not needed to control three power options through a joystick. Given that the power tilt/recline system is not medically necessary, the headrest and hardware for this item is also not covered.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power tilt/recline system, head rest, and expandable controller with harness and electronic connection for a Group 3 power wheelchair (PWC).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on October 19, 2020.

You asked the Plan to pay for the self-administered drug. You say that you were told not to bring any prescription medications with you to the hospital, that all medications would be covered by insurance and dispensed from the hospital. You say that you had a total of 4 eye drops dispensed while you were in the hospital. You also say that now it is being denied. The Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on October 19, 2020.

Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 in the Medicare rules section 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on May 20, 2021 with syncope and nausea after a fall. She suffered a large scalp laceration and was found to be anemic. She has no skilled nursing needs. She has skilled therapy but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve a partial lower denture. We decided that the Plan does not have to pre-approve a complete upper denture.

You asked the Plan to pre-approve a complete upper denture, and a partial lower denture. You say that you need replacements because your complete upper denture is broken, and the lower partial denture does not fit. The Plan says that you exceeded the maximum count allowed per period.

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 decided that the Plan has to pre-approve a partial lower denture. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a partial lower denture have been met. Specifically, the EOC states that one procedure is covered every 5 years. The EOC does not disclose that only one lower denture code is covered once every 5 years. The Plan previously approved a lower partial denture (D5214) on September 18, 2018. The Plan has not previously approved procedure code D5212. Therefore, we decided that the Plan has to pre-approve a lower partial denture - resin based (D5212).

We also decided that the Plan does not have to pre-approve complete upper denture. 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 have not been met. Specifically, the record shows that you had exceeded the frequency limit for this code prior to this service on August 28, 2018. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), cone beam
computerized tomography (CT) capture and interpretation with field of view of one full dental arch - mandible
(D0365), consultation - diagnostic service provided by dentist or physician other than requesting dentist or
physician (D9310) provided March 20, 2019.

You asked the Plan to pay for the panoramic x-rays, cone beam CT capture and dental consultation. You say
that you had a bad experience at the dental office and do not wish to pay for the experience. The Plan denied
your request. The Plan says that cone beam CT captures and dental consultations are not covered under your
benefits. Panoramic x-rays are only covered once every 36 months and this benefit has already been used.

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 cone beam CT capture and dental
consultation are not among those covered under this benefit. A panoramic x-ray was covered by the Plan on
September 23, 2019. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic
image (D0330), cone beam computerized tomography (CT) capture and interpretation with field of view of one
full dental arch - mandible (D0365), consultation - diagnostic service provided by dentist or physician other
than requesting dentist or physician (D9310) provided March 20, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure (97110) provided on June 19, 2020.

You asked the Plan to pay for the therapeutic procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is an appropriate Healthcare Common Procedure Coding System (HCPCS) code (G0151) for the billed service.

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 97110 is not supported in the record. Specifically, the documentation submitted indicates that the billed service was provided in a home setting. There is a more appropriate CPT code for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure (97110) provided on June 19, 2020.