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

We decided that the Plan does not have to pre-approve a telephone alert system.

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a telephone alert system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed code cannot be verified.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. The records do not indicate the time spent for the critical care on the date of service at issue. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance service, advanced life support, emergency transport, level 1 (als 1 - emergency) (A0427PH), and ground mileage, per statute mile (A0425PH).

You asked the Plan to waive the copayment for ambulance transportation. You say that you should not have to pay the copayment. The Plan denied your request. The Plan says the copayment was applied correctly.

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 $250 copayment for ambulance services.

You have been asked to pay a $250 copayment for ambulance transporation. The services at issue fall 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 copayment for ambulance service, advanced life support, emergency transport, level 1 (als 1 - emergency) (A0427PH), and ground mileage, per statute mile (A0425PH).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services.

You asked the Plan to pre-approve the services provided. You say that there is no visit maximum for chiropractic services. The Plan denied your request. The Plan says the services are not covered when billed by a chiropractor.

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 file shows that the enrollee received manipulation of extraspinal regions, mechanical traction, and electrical stimulation. These services are not manual manipulation of the spine, and are not covered. Therefore, we decided that the Plan does not have to pre-approve the medical services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Purewick External Catheter system.

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says successful treatment could reduce incontinence.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the Purewick External Catheter system.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on May 5, 2020.You asked the Plan to pay forthe ambulance services. You say that you did not request this service.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 isno transport. The ambulance company did not provide transport services on May 5, 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 forthe ambulance services provided on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the services to be provided at an out-of-network
provider.
You asked the Plan to pre-approve the services. You say that the service is necessary. The Plan denied your
request. The Plan says the service is not necessary.
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 provider at issue in this case is not a network provider with the Plan. 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 services. Our physician reviewer found palliative care can be done with
an in-network provider.
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.
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 the services. Therefore, we decided that the Plan does
not have to pre-approve the services to be provided at an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 20, 2020.
You asked the Plan to pay for the ambulance services. You say that the restaurant called for the ambulance service and you were not able to leave without your mother. 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 February 20, 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 February 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on April 24, 2020.You asked the Plan to pay forthe ambulance services. You say that you disagree because you said it cost you less to be transported to the hospital than to have no transport at all.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 April 24, 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 forthe ambulance services provided on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe specialist office visits provided from September 20, 2019 to December 12, 2019.You asked the Plan to waive the copayments forthe specialist office visits. You say that the office visits were billed by mistake and you should not pay for non-existent services. You say you should be reimbursed the copayment amounts.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 $35 copayment per specialty care visit. You have been asked to pay a $35 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical records show that you received the PICC line change and cleaning during the visits.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 copayments forthe specialist office visits provided from September 20, 2019 to December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve new eyeglasses.
You asked the Plan to pre-approve these services. You say that you are on a fixed income and cannot afford new glasses. The Plan denied your request. The Plan says the services are not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one pair of routine eyewear per calendar year. We looked at the file and the Plan's rules. The file shows that you received routine eyewear for which the Plan approved and paid on March 9, 2020. Further routine eyewear is not covered by Medicare or your supplemental routine vision benefit. Therefore, we decided that the Plan does not have to pre-approve new eyeglasses.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D4381) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 pre-approve dental services (D4381) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring (G0453), somatosensory testing (95938), electroencephalogram (EEG) during surgery (95955), needle electromyography (95861), and the unlisted neurological or neuromuscular diagnostic procedure (95999).

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services are not payable as the claim was submitted untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for these services was not filed until July 30, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring (G0453), somatosensory testing (95938), electroencephalogram (EEG) during surgery (95955), needle electromyography (95861), and the unlisted neurological or neuromuscular diagnostic procedure (95999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve home health services. You say that you would like approval for these services. The Plan denied your request. The Plan says there are in-network providers available for these 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 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 home health 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 pay for the hearing aids.

You asked the Plan to pay for the hearing aids. You say that the hearing aids you purchased are a better fit, and work very well for you. The Plan denied your request. The Plan says hearing aid devices are limited to the devices available through the program.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.

We looked at the file, and the Plan's rules. The records do not show that you received hearing aids through the program. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system and electronic connection for a 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 services are not covered.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is not covered. The rules say that an electronic connection is covered when specific criteria are met.

We looked at the file and Medicare rules. The requested power seat elevation system does not serve a purpose that is primarily medical in nature and is not covered by Medicare. The file does not show that the electronic connection is needed to control the approved power options through a joystick. 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 seat elevation system and electronic connection for a power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus shot.

You asked the Plan to pay for the services provided. You say that you were told the shot was covered. The Plan denied your request. The Plan says the service is not covered under Part B.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services provided. The Plan follows the same rules.

The records do not show that you were injured or directly exposed to any illness related to the services provided. Therefore, we decided that the Plan does not have to pay for the Tetanus shot.

Benefits for the services provided 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment, lift chair (E1399).

You asked the Plan to waive the coinsurance for a lift chair. You say that the item should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.

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 20% coinsurance for durable medical equipment. 

You have been asked to pay a 20% coinsurance for a lift chair. This item falls within the durable medical equipment 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 coinsurance for durable medical equipment, lift chair (E1399)
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services (97140, 97110).

You asked the Plan to waive the copayment for physical therapy. You say that you will require several sessions of therapy and cannot afford the copayments. The Plan denied your request. The Plan says outpatient rehabilitation services such as physical therapy has a $35 copayment per session.

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 $35 copayment for outpatient rehabilitation services.

You have been asked to pay a $35 copayment for physical therapy. Physical therapy falls within the outpatient rehabilitation 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 copayment for physical therapy services (97140, 97110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services.

You asked the Plan to pay for the services provided. You say that the enrollee's carpal tunnel was discussed in regards to another injection. The Plan denied your request. The Plan says the billed services cannot be verified.

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 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting. The CPT Code Manual definition of code J1100 is Injection, dexamethasone sodium phosphate, 1 mg.

We find that CPT codes 20611 and J1100 are not supported in the medical record. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the medical services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift (stair glide).

You asked the Plan to pre-approve a stair lift. You say that you need this system to bring groceries and other items into your house and wish to prevent a major accident in advance. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because a stair lift is not covered by Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. 

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair lift (stair glide).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis.

You asked the Plan to pay for the prophylaxis. You say that you received a document from the Plan stating services performed by an out-of-network provider would be covered. The Plan denied your request. The Plan says the treating provider opted out of Medicare. The Plan also says that services performed by a privately contracted provider 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.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the prophylaxis.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayments for the podiatry visits.

You asked the Plan to waive the copayments for the podiatry visits. You say that no services were provided at either visit. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit medical records to support that services were provided. Therefore, the plan has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayments for the podiatry visits.

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.