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

We decided that the Plan does not have to pay forankle foot orthoses (L1906) provided on January 7, 2020.You asked the Plan to pay forankle foot orthoses. 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 include an itemized delivery ticket or proof of delivery indicating the billed supplies were dispensed to the member nor did the submitted documentation indicate the provider discussed the need for the billed supply code.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the itemsat issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Additionally, the record does not indicate that the provider discussed the need for the billed supply code.Therefore, we decided thatthe Plan does not have to pay forankle foot orthoses (L1906) provided on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient behavioral health facility.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says a 24/7 secure place is not needed to be safe and take care of needs.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not meet criteria for this admission for inpatient mental health treatment. You were not shown to be a danger to yourself or others. You were without agitation and aggression, without perceptual disturbance, including auditory or visual hallucinations. The health plan's denial of inpatient psychiatric services appears appropriate. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient behavioral health facility.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a sigmoidoscopy provided on November 11, 2019.
You asked the Plan to waive the copayment for a sigmoidoscopy. You say that this procedure should be considered preventative for you. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $50 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you received a sigmoidoscopy on November 11, 2019. A sigmoidoscopy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a sigmoidoscopy. A sigmoidoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a sigmoidoscopy provided on November 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on December 19, 2019 through December 26, 2019.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because CPT code S9328 is a valid code per Medicare.The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is not valid for Medicare purposes.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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on December 19, 2019 through December 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport and ER visit provided on December 5, 2019.You asked the Plan to waive the copayment forthe ambulance transport and ER visit. You say that if you were taken to the VA emergency room it would have cost you nothing for the ambulance or emergency room.The Plan denied your request. The Plan says the copayments 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 per one-way trip and a $90 copayment per emergency department visit.You have been asked to pay a $250 copayment for the ambulance transport and a $90 copayment for the ER visit. The ambulance transport falls within the "Ambulance services" benefit category. The ER visit falls within the "Emergency care" benefit category. The records show that you were transported by ambulance to the hospital where you were treated in the ER. 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 forthe ambulance transport and ER visit provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient office visit rendered to you on January 3, 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 procedure code 99203 is not supported.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 99203 is Level 3 new patient office or other outpatient visit, typically 30 minutes.We find that CPT code 99203 is not supported in the medical record. Specifically, the file shows that you previously received services from a physician within the same provider practice on October 21, 2019; therefore, a new patient office visit does not apply. 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 new patient office visit rendered to you on January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7140) for teeth # 12 and 16 provided on
January 13, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says extractions are
not a covered service.
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, extractions are not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extractions
(D7140) for teeth # 12 and 16 provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aspiration and/or injection of large joint/joint capsule for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says no new clinical documentation was sent to support this request.
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 the procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the review of the provided documentation has failed to find a history of the current illness, a physical examination, a diagnosis and/ or a detailed plan of care. The review has determined that the items/services at issue in this case is not medically reasonable and 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve aspiration and/or injection of large joint/joint capsule for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator for the enrollee.You asked the Plan to pre-approve a spinal electrical osteogenesis stimulator. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that criteria for coverage has not been met.The Plan follows Medicare rules. Medicare rules say that spinal electrical osteogenesis stimulator is covered if the above criteria has been 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 pre-approve a spinal electrical osteogenesis stimulator. Our reviewer says that a spinal electrical osteogenesis stimulator is not medically reasonable and necessary for the enrollee in this case. The enrollee had a one level spine fusion performed. Nine months have not passed since surgery. There is no previous nonunion history. Our physicianreviewer found that the enrollee's condition does not meet Medicare criteria for a spinal electrical osteogenesis stimulator.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 spinal electrical osteogenesis stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approvea spinal electrical osteogenesis stimulator for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on November 15, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim needs to be
submitted to the primary insurer.
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. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified
Allied as the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not
have to pay for the services provided to the enrollee on November 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for cataract surgery provided in Turkey on October 24, 2019.
You asked the Plan to pay for the cataract surgery provided in Turkey. The Plan denied your request. The Plan says the documentation provided does not support the charges is being requested for reimbursement. When submitting a request for reimbursement for out of network care, documentation must be submitted reflecting what the member paid out of pocket and the Plan's cannot substantiate the charges paid. The services in question could have been rendered within health plan's in-network providers if the member resided in the country as well.
The Plan must follow Medicare rules. Medicare rules say that Medicare says that health plans must pay for emergency and urgently needed services. The Plan contract says that coverage for urgently needed care worldwide is a supplemental benefit. You must send the Plan the bill along with documentation of any payments you have made to substantiate the charges paid. We looked at the file and Medicare rules. The file shows that proof of payment has not been provided to the Plan. Without the proof payment the Plan cannot substantiate the amount paid and verify the charges. Therefore, we decided that the Plan does not have to reimburse you for cataract surgery provided in Turkey on October 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ambulance trip provided by provider on October 21, 2019.You asked the Plan to waive the copayment foran ambulance trip. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $225 copayment for ambulance services. You have been asked to pay a $225 copayment for an ambulance trip. An ambulance trip 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 copayment foran ambulance trip provided by provider on October 21, 2019.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 based on review of the available records, the enrollee is reported to be medically stable with no evidence of need for supervision by PMR Physician or needs acute rehab nursing care. The enrollee does not require an intensive therapy program. IRF admission is not medically necessary based on the current functional status and medical stability. Medicare coverage criteria for IRF care are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the physiological study and the duplex scan provided on August 19, 2019.
You asked the Plan to waive the coinsurance for the physiological study and the duplex scan. You say that you had already paid your copayment for the office visit and you should not be responsible for any additional charges. 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 20% of the cost for Medicare-covered diagnostic procedures and tests. You have been asked to pay a total of $68.17 for the physiological study and the duplex scan. The physiological study and the duplex scan fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the diagnostic tests are considered separate services.
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 the physiological study and the duplex scan provided on August 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot orthotics (L3000).
You asked the Plan to pre-approve custom foot orthotics. You say that you are requesting a reconsideration of the Plan's denial as you have been diagnosed with Hallux Rigidus, a very painful condition that is triggered, or is manifest by, a growth on the inside side bottom of the right foot. The Plan denied your request. The Plan says that custom foot orthotics are not a covered benefit under your contractual policy for your condition.
Medicare rules state that supportive devices for the feet (such as custom foot orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics (L3000).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on November 20, 2019.
You asked the Plan to pay for the paramedic intercept services. The Plan denied your request. The Plan says that paramedic intercept services are covered only in rural locations.
The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on November 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Psychotropic Assay rendered on September
12, 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 testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the provider 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
testing was not medically necessary. Our physician reviewer found the enrollee has recurrent moderate major
depressive disorder without psychotic features. The psychiatric progress note dated September 12, 2019
documents he was maxed out on Effexor DR and can't tolerate a higher dose. Trazodone was being used for
sleep. The enrollee had been using THC. The documentation does not support that the requested testing was
ordered by a licensed psychiatrist or neuropsychiatrist who was contemplating an alteration in neuropsychiatric
medication for this patient diagnosed with major depressive disorder (MDD) who is suffering with refractory
moderate to severe depression (based upon DSM-V criteria) after at least one prior neuropsychiatric medication
failure; therefore, the testing was not 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 Psychotropic Assay rendered on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning (99497) provided on September 11, 2019.
You asked the Plan to pay for the advance care planning. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted medical records did not indicate that advance care planning was performed.
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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. We find that CPT code 99497 is not supported in the record. Specifically, the record does not indicate that advance care planning was rendered on this date of service. Based on this information, we decided that Medicare rules for coverage of the advance care planning have not been met. Therefore, we decided that the Plan does not have to pay for advance care planning (99497) provided on September 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation services.
You asked the Plan to pre-approve the transportation services. You say that the enrollee needs transportation to
appointments. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance.
The Plan follows the same rule.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Medicare rules for coverage of the transportation services have not been met. Therefore, we decided
that the Plan does not have to pre-approve routine transportation services.