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

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311,
E2313, E2377) for the enrollee.

You asked the Plan to pre-approve the additional accessories. 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. 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 additional accessories. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation does not support that the requested additional power wheelchair
accessories are medically necessary for the enrollee in this case. The enrollee can reasonably use the switches
to control the power options.

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 additional accessories have not been met. Therefore, we decided that the
Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on April 24, 2021.
You asked the Plan to pay for the dental service. You say that you received a bill for $200 just for a consultation. You say that the dental clinic offered many procedures on the spot, but they were too pricey. You say that you did not have any procedures done. You also say that you would like a refund. The Plan denied your request. The Plan says you pay 80% of Specialist's Usual & Customary Fee per procedure when receiving specialty services approved by the Dental Plan through the specialty referral process explained above. The Plan also says that the claim was processed correctly.
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, dental services performed by a specialist have an 80% coinsurance. The record shows that the total charge for the consultation was $250. $250 x 80% = $200. Additionally, the record shows that the consultation was performed by an oral surgeon.
Therefore, we decided that the Plan does not have to pay for the consultation (D9310) provided on April 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a myoelectric elbow-wrist-hand-finger orthosis for the enrollee.

You asked the Plan to pre-approve the orthosis. You say that this is medically necessary based on the enrollee's previous medical history. The Plan denied your request. The Plan says the enrollee is able to reside independently and drive.

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 orthosis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical documentation by the ordering physician does not support that the requested orthotic device is medically reasonable and necessary for the enrollee in this case. The ordering physician does not indicate that the requested orthotic device is an accepted standard of medical practice that meets but does not exceed the enrollee's medical need, and does not indicate that the device is at least as beneficial as existing and available medically appropriate alternatives.

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 orthosis have not been met. Therefore, we decided that the Plan does not
have to pre-approve a myoelectric elbow-wrist-hand-finger orthosis for the enrollee.
Appeal type: Transportation
Decision: Unfavorable


We decided that the Plan does not have to pay for air ambulance transport provided on October 15, 2020. 
  
You asked the Plan to pay for air ambulance transport. The Plan denied your request. The Plan says air 
ambulance transport was not medically necessary. 
 
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 air ambulance transport. Our reviewer says 
that air ambulance transport was not medically necessary. Our physician reviewer found that the enrollee is a 
72-year-old male with a left popliteal aneurysm, which was pulseless and with paresthesia. The enrollee was 
transported via air ambulance to receive interventional radiology services at the receiving hospital. He was 
started on heparin drip, which was continued during transport, but he did not require oxygen. The transferring 
hospital appeared to not have adequate facilities to treat the enrollee. Ambulance services were required. Other 
means would have placed the enrollee at risk as heparin needed to be continued during transportation. The 
documentation did not show that ground ambulance would have placed the enrollee at risk as it would have 
been a shorter trip. Air transport took 58 minutes whereas ground transport would have taken approximately 32 
minutes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of air ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for air ambulance transport provided on October 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pay for IRF care. You say that you would rather have one-on-one intensive rehabilitation. The Plan denied your request. The Plan says you do not meet criteria for an IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the records should be reviewed, and the 
claim should be processed for payment. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on December 1, 2020.  
You asked the Plan to pay for the testing services. You say that medical necessity has been established. The 
Plan denied your request. The Plan says the testing is not a benefit for the diagnoses listed on the claim.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered.  
We looked at the file and the rules. The medical records provided show the enrollee was seen for surgery 
clearance. The records do not indicate any abnormal signs or symptoms associated with a risk of bleeding or 
abnormalities. The testing services were requested for screening purposes. Medicare does not cover this testing 
for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing provided on 
December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.

You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says a fixed height hospital can be approved.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or

2. Requires attachments which can only be attached to a hospital bed; AND

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 bed. Our reviewer says that the
requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does
not clearly reveal that your condition has failed positioning of the bed in ways not feasible in an ordinary bed
or why positioning of the bed in other ways is not feasible. The documentation does not clearly support a need
for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary
bed. The request for a semi-electric hospital bed is not medically necessary for you.

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 bed have not been met. Therefore, we decided that the Plan does not have to
pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (E1230).
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare requires submission of a physician's order with clinical notes documenting medical history and recommendations in order to determine the medical necessity for a power operated vehicle.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 scooter. Our reviewer says that the requested scooter is Our physician reviewer found the medical progress notes do not clearly support that you have a personal mobility deficit that impairs participation in MRADLs in the home. The medical progress notes suggest that you use a cane or walker. While you may have the ability to operate the scooter, the documentation does not support that the requested device is medically necessary, or will significantly improve your ability to articipate in MRADLs in the home. 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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter (E1230).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (G0483) provided to the enrollee on
November 5, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Units) remains not
supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

We find that HCPCS code [Enter billing code at issue (e.g. 43856, K0002, etc.)] is not supported in the medical
record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when
the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the
records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing services (G0483) provided to the enrollee on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network acupuncture services provided from March 22, 2021, to April 29, 2021.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan because you had prior authorization to go out of network. The Plan denied your request. The Plan says your providers office confirmed you did not have prior authorization, nor did they request prior authorization on your behalf.

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 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 out of network acupuncture services provided from March 22, 2021, to April 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a second chest x-ray (71045) provided on June 30, 2020.
You asked the Plan to pay for a second chest x-ray. You say that this service is not a duplicate. The Plan denied your request. The Plan says this service was previously billed and paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that a second unit of CPT code 71045 is not supported in the medical record. The medical record only supports 1 unit of CPT code 71045, which was previously billed and paid. Based on this information, we decided that Medicare rules for coverage of a second chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a second chest x-ray (71045) provided on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing exam provided to you on January 21, 2021.
You asked the Plan to pay for the exam. The Plan denied your request. The Plan says the benefit limit has been exceeded.
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 one routine hearing exam per year. We looked at the file and the Plan's rules. The records show that you had a covered hearing exam on January 5, 2021. The Plan only covered one hearing exam per year. This means that the requested hearing exam exceeds the benefit limit and is not covered. Therefore, we decided that the Plan does not have to pay for the hearing exam provided to you on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and topical 
application of fluoride varnish provided on January 18, 2021 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and topical application of fluoride 
varnish. You say that these services are supposed to be covered by the Plan. You also say that you have known 
this dentist for many years, trust him, and would like these services to be covered. The Plan denied your 
request. The Plan says the provider that performed these services is not within the Plan's network. The Plan 
also says that covered services must be received from a participating, in-network, general dentist's office. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation, prophylaxis, and topical application of fluoride varnish provided on January 18, 2021 by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided on March 10, 2021.

You asked the Plan to waive the deductible for laboratory services. You say that you feel that laboratory services should not apply toward the deductible. 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. Your contract with the Plan says that there is a $300 deductible for outpatient diagnostic tests and therapeutic services and supplies. 

You received laboratory services on March 10, 2021. Due to the reprocessing of claims, you had only paid $253.56 toward the $300 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $46.44. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies.

The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for
outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation
that had not been met at the time laboratory services was received on March 10, 2021. Therefore, we decided
that the Plan does not have to waive the deductible for laboratory services provided on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4342 x2) 
provided on January 5, 2021. 
 
You asked the Plan to pay for the scalings and planings. You say that these services were done in place of a 
routine prophylaxis as a precautionary measure to avoid potential gum disease. The Plan denied your request. 
The Plan says this service is not a covered benefit under your dental plan. 
 
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 two 
periodontal scalings and root planings (D4342 x2) provided on January 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from December 20, 2020, to December 22, 2020 and billed under code G0299.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says this code has a status indicator of "I" which excludes payment for Medicare claims. Medicare uses a different code to report or claim these services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code reported has a status code indicator that prevents payment for Medicare claims. A corrected claim is required. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from December 20, 2020, to December 22, 2020 and billed under code G0299.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you submitted updated medical records and 
the claim should be processed. The Plan denied your request. The Plan says Original Medicare is responsible 
for payment. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on January 15, 2021.