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

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that while at an outdoor event you fainted. When you came to, a group of people were trying to assist you and one of them called for an ambulance. You say that the ambulance arrived and finished the medical evaluation that had been started by local fire department personnel. You decided to not go to the hospital and instead contacted your doctor to follow up. You say that you did not call for the ambulance and asked those around you to not call an ambulance as well. You believe you should not be liable for the charges.The Plan denied your request. The Plan says theseservices 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 July 6, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe porcelain crowns (D2740) for teeth # 20 and 30, core buildup (D2950), root canal (D3320), upper partial denture (D5211), and the lower partial denture (D5212) provided on July16, 2019 by the out of network provider.You asked the Plan to pay forthe dental services. The Plan denied your request. The Plan says dental services you receive from an out of network provider are not covered. The Plan also says that the provider in this case is not a network provider.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 Planoffers a dental benefit in excess of Medicare coverage, dental services are not covered when you receive them from an out of network provider.Therefore, we decided that the Plan does not have to pay forthe porcelain crowns (D2740) for teeth # 20 and30, core buildup (D2950), root canal (D3320), upper partial denture (D5211), and the lower partial denture (D5212) provided on July 16, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids purchased on June 26, 2019.You asked the Plan to pay forthe hearing aids. You say that the medical records will support medical necessity for the services in dispute.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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. The Plan pays for hearing aids only Hearing aids are covered every 2 years. Hearing aids are not covered when provided by an out of network provider. We looked at the file and the Plan's rules. 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 forthe hearing aids purchased on June 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe impression and custom preparation for an oral surgical splint provided on July 11, 2019 by out of network provider.You asked the Plan to pay forthe surgical services. You say that your office requested authorization for a 3-month period. You say that only a 1-month period was approved by mistake. You also say that the Plan refused to extend the authorization.The Plan denied your request. The Plan says authorization was not obtained for the date that you received the service. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. 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 forthe impression and custom preparation for an oral surgical splint provided on July 11, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapproveintermittent limb compression device.You asked the Plan to preapproveintermittent limb compression device. You say that you require the compression pump to alleviate swelling and retention that has occurred after surgery.The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare when there are no measurements of the lymphedema and when there is no treatment plan.The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when the documentation contains prognosis and diagnosis, measurements which show the severity of the condition, and a demonstrated initial treatment with the device.  The file does not show that there is a documented treatment plan or measurements of the lymphedema. There also isn't a documented initial trial (with measurements) of the pump. Therefore, we decided that the Plan does not have to preapproveintermittent limb compression device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you were very sick while on vacation with your friends. Yousay that you consulted a hotel doctor who recommended that you call for an ambulance. When the ambulance arrived, the responders evaluated you and gave you treatment. You said that you decided not to go to the hospital because you were told that there wasan airborne virus in the city at the time.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 July 18, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora Low-Dose Computed Tomography (LDCT) screening provided on July 26, 2019.You asked the Plan to pay forLDCT screening. You say that your previous test showed some abnormalities and another scan was recommended in 6 months, and your provider was told that prior authorization was not required for this test.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is only covered once every 12 months and you received an LDCT test on January 16, 2019.The Plan must follow Medicare rules. Medicare rules say that Low-Dose Computed Tomography (LDCT) screenings are covered once annually for qualified beneficiaries. The Plan contract says that the Plan covers LDCT screenings once every 12 months for qualified individuals, in accordance with Medicare rules.We looked at the file and Medicare rules. You received an LDCT screening test on January 16, 2019, therefore 12 months had not passed before this LDCT test was performed. Based on this information, we decided that Medicare rules for coverage of LDCT screening have not been met.Therefore, we decided that the Plan does not have to pay fora Low-Dose Computed Tomography (LDCT) screening provided on July 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for testing provided August 17, 2018.You asked the Plan to pay forthe testing. You say that these services were medically necessary.The Plan denied your request. The Plan says Train of Four testing cannot be paid as a separate line item, as the service is bundled with Neuromonitoring codes already paid.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, we have confirmed that code 95999 has a bundled relationship with other Neuromonitoring codes already paid and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay for testing provided August 17, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvewaterjet ablation of the prostate (0421T).You asked the Plan to pre-approvewaterjet ablation of the prostate. You say that the requested service is medically necessary.The Plan denied your request. The Plan says the service is listed as not reasonable and necessary. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that a service that is considered to be not reasonable and necessary will be denied as such. We looked at the file and Medicare rules. Specifically, the service is listed as not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of waterjet ablation of the prostate have not been met.Therefore, we decided that the Plan does not have to pre-approvewaterjet ablation of the prostate (0421T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you contracted polio when you were young and are still dealing with the side effects. You say that without the requested orthotics you are unable to walk as well clean your home, go grocery shopping, or live your life. Yousay that the orthotics are a necessity.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as 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-approvefoot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic manipulative treatment (98941) provided on September 10, 2019.You asked the Plan to pay forthese services. You say that the chiropractic care provided was medically necessary.The Plan denied your request. The Plan says the chiropractic manipulative treatment provided was not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 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 chiropractic services provided were not medically necessary. Our physician reviewer found the enrollee is seen on a monthly basis for various aches and pains. There is no evidence from the submitted documentation that further clinical improvement can reasonably be expected from continuous ongoing care. The enrollee exhibits arthritic/degenerative findings and the chiropractic treatment is to prevent deterioration of a chronic condition. This is considered maintenance care, which is not supported or allowed per Medicare guidelines.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.Specifically, the only chiropractic service Medicare covers is manual manipulation of the spine to correct subluxation. The services provided in this case were chiropractic maintenance care,which is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay forthe chiropractic manipulative treatment (98941) provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 16, 2019.You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 did not pre-approve the servicesat issue. We found no exception that would requirethe Plan to pay for these services. Therefore, we decided thatthe Plan does not have to pay for a domiciliary or rest home visit provided on July 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.You asked the Plan to pre-approveDurolane. You say that the Durolane is medically necessary.The Plan denied your request. The Plan says Durlane cannot be considered until plan preferred alternatives have been used.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Durolane. Our reviewer says that coverage rules have not been met. Our physician reviewer found the enrollee has not trialed the plan preferred agents, Orthovisc and Monovisc.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met.Therefore, we decided that the Plan does not have to pre-approveDurolane.
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 the requested services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for IRF care has not been 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 available records, you do not meet criteria for coverage of IRF. You are currently medically stable and there is no evidence ofcomplex medical issues that require monitoring by an inpatient physician three times per week or acute rehab nursing care. While you may benefit from continuing physical therapy (PT) and occupational therapy (OT), there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The records do not support you can currently participate in 3 hours of therapy per day.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran X-ray (72040) provided on September 10, 2019.You asked the Plan to waive the copayment forthe X-ray. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.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 $105 copayment for Radiology Services. You have been asked to pay a $68.83 copayment for the X-ray. The X-ray falls within the Radiology Services benefit category. The Medicare allowable amount of $68.83 is less than the $105 copayment listed in the contract so it was charged instead. 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 X-ray (72040) provided on September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on February 28, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This meansthat the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on February 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested services are medically 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. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for osteomyelitis of his toe resulting in an amputation. The enrollee is receiving wound care and antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Flexitouch Advanced System. You asked the Plan to pre-approvethe pneumatic compression device and lower garments. You say that Tactile Medical will be pleased to negotiate a highly competitive in-network payment rate.The Plan denied your request. The Plan says the Flexitouch Advanced System is available from an in-network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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 itemsat issue in this appeal. We found no exception that would require the Plan to pre-approve these items.Therefore, we decided that the Plan does not have to pre-approvethe Flexitouch Advanced System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At leastfour weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652)