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

We decided that the Plan has to pay services provided by provider on September 25, 2019.You asked the Plan to pay the air ambulance service allowance. You say that the transfer was medically necessary for the enrollee to receive the appropriate level of care.The Plan denied your request. The Plan says that they have paid the ground rate with mileage to the nearest facility.The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance services. Our reviewer says that the services were medically necessary. Our physician reviewer found based on the documentation provided the health plan's denial should be overturned. The enrollee presented to a small critical access hospital complaining of chest pain.  The enrollee appeared to be experiencing acute coronary syndrome (ACS) and was transported to a tertiary facility for a higher level of care.  The health plan argues that another facility (MHN) was closer, but the health plan has provided no information that that facility actually had the services necessary to care for the enrollee (interventional cardiology, CT surgery). It does appear that the enrollee went to the closest, most appropriate facility, for what was medically necessary care. Therefore, the air medical transport should be 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 the air ambulance services have been met.Therefore, we decided that the Plan has to pay the air ambulance service allowance for services provided by provider on September 25, 2019.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: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that physicians in the same group practice who are in the same specialty must bill and be paid as
though they were a single physician. If more than one evaluation and management (face-to-face) service is
provided on the same day to the same patient by the same physician or more than one physician in the same
specialty in the same group, only one evaluation and management service may be reported unless the
evaluation and management services are for unrelated problems. Instead of billing separately, the physicians
should select a level of service representative of the combined visits and submit the appropriate code for that
level. You can find this rule in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.5.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.
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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the records do not indicate that there are significant, or complex medical/nursing
issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication
management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of
therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in
an IRF level of care at this time.
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a speech generating device (SGD) for the enrollee.
You asked the Plan to pre-approve a SGD. You say that this is medically necessary. The Plan denied your request. The Plan says that the member's condition is progressive with loss of word recognition therefore the device will not resolve the member's communication needs.
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 a SGD. Our reviewer says that a SGD is
not considered medically reasonable and necessary in this case. The enrollee has primary progressive aphasia. Reviewed documentation included a detailed speech therapist consultation summary and primary care provider notes. The notes do not detail current cognitive status or limitations with natural modes of communication. The primary care provider note the enrollee's primary diagnosis was stable over the course of several months. Without the support of the documentation, medical necessity cannot be determined. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a SGD. 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 SGD have not been met. Therefore, we decided that the Plan does not have to pre-approve a speech generating device (SGD) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit, 60 minutes (90837) provided on
September 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy visit, 60 minutes. You say that the services were provided and
payment should be rendered. The Plan denied your request. The Plan says non-emergent services rendered by
non-participating providers in non-participating facilities require prior authorization, therefore coverage criteria
has not been met.
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 a psychotherapy visit, 60 minutes (90837)
provided on September 16, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on September 9, 2019.
You asked the Plan to pay for drug tests. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order or intent to order the specific lab services billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on November 18, 2019.You asked the Plan to pay forthe services. You say that you needed this taken care of right away.The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network 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 services 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 forthe medical services provided to you by an out-of-network provider on November 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient hospital services rendered to you on June 14, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance 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 40% coinsurance for out-of-network inpatient hospital care.
Review of the file shows that you received inpatient services at an out-of-network hospital on June 14, 2019. You have been asked to pay a 40% coinsurance for these services. These services fall within the out-of-network inpatient hospital care 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. The file shows that the Plan previously allowed a one-time payment for services from the out-of-network provider as a one-time courtesy and advised you that future services would be subject to the out-of-network coinsurance. Therefore, we decided that the Plan does not have to waive the coinsurance for the inpatient hospital services rendered to you on June 14, 2019.
Appeal type: Home Health
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 the OON services. The Plan denied your request. The Plan says the requested service is available in-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKisqali for the enrollee.You asked the Plan to pre-approveKisqali. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.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 pre-approveKisqali for the enrollee.Benefits for Kisqalimay be available under Medicare Part D.Contactthe 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 pre-approve a Freestyle Libre 14 day reader.
You asked the Plan to pre-approve a Freestyle Libre 14 day reader. You say that the items 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 plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-preferred brands). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14-day reader have not been met. Specifically, medical records were not provided. Without this documentation medical necessity for the specific brand requested is not able to be established. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 24, 2019 by an out of network (OON) provider.You asked the Plan to pay for specialist visit. You say that this procedure was medically necessary, and you had a referral.The Plan denied your request. The Plan says the denial of payment for this service is correct, because a referral is required prior to obtaining service from a specialist.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. A referral was not obtained for this service according to the Plan's rules, and the Plan did not pre-approve this service. 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 the medical services provided on May 24, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 16, 2019
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 rendered by a non-contracted provider without prior authorization.
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 the medical services provided on January 16, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vestibuloplasty -ridge extension, two sinus augmentations with bone or bone substitutes, and two extractions provided on April 29, 2019.You asked the Plan to pay for the vestibuloplasty, sinus augmentations, and extractions. You say that the surgery was to remove four permanent bridges compromised by extensive bone loss and periodontal disease. You also say that if this had been left untreated, a risk of systemic conditions existed such as cardiovascular events.The Plan denied your request. The Plan says these services are not covered according to your plan benefits.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay for the vestibuloplasty -ridge extension, two sinus augmentations with bone or bone substitutes, and two extractions provided on April 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
You asked the Plan to pre-approve the electric hospital bed. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says a hospital bed that is electric is not a Medicare covered benefit and is excluded from coverage under your contractual policy.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate for you in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for screening tests provided on November 14, 2019.
You asked the Plan to pay for screening tests. You say that these codes were billed correctly. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not covered for the diagnoses listed and were performed for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, screening tests, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for screening tests provided on November 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto
You asked the Plan to pre-approve Xarelto. You say that any other medication will not be sufficient for the enrollee. The Plan denied your request. The Plan says Xarelto to be administered at home is not covered under the Part B benefit.
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 pre-approve Xarelto 
Benefits for Xarelto 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 30, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that you cannot afford to pay the copayment.The Plan denied your request. The Plan says that cost shares are a contractual obligation.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 $200 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $200copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing isa 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 ambulance transport provided on September 30, 2019.
Appeal type: Transportation
Decision: Unfavorable


We decided that the Plan does not have to pay for ambulance supplies provided on June 2, 2019.
You asked the Plan to pay for disposable supplies (A0394). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the services were paid but supplies are not paid separately.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of disposable supplies (A0394) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance supplies provided on June 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on October 28, 2019.
You asked the Plan to pay for the endodontic therapy. You say that these services were not cosmetic in nature and were necessitated by the deterioration of the tooth and the root. The Plan denied your request. The Plan says this service 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 the endodontic therapy provided on October 28, 2019.