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

We decided that the Plan does not have to pay for the ambulance services provided on October 14, 2020.

You asked the Plan to pay for the ambulance services. You say that you fell, and the medics treated you in place and assisted you back to your bed. 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 October 14, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) on November 17, 2020.

You asked the Plan to waive the copayment for these services. You say that you needed the MRI after having COVID-19. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for diagnostic radiology other than CT scans performed by a provider other than your primary care physician.

Review of the file shows that you received an MRI of the abdomen on November 17, 2020. You have been asked to pay a $275 copayment for these services. These services fall within the diagnostic radiology other than CT scans performed by a provider other than your primary care physician 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 the magnetic resonance imaging (MRI) on November 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the services 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. 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 there are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan. The requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be
furnished safely and effectively only on an inpatient basis.

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-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services (G0156).

You asked the Plan to pre-approve home health aide services. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee does not have skilled needs.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 

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 home health aide services. Our reviewer says that the requested home health aide services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing or therapy 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 home health aide services have not been met.Therefore, we decided that the Plan does not have to pre-approve home health aide services (G0156).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for CPAP device (CPT code E0601) and miscellaneous DME supply or accessory, not otherwise specified (CPT Code A9999) provided on September 29, 2020.

You asked the Plan to pay for the DME. You say that the claim was denied in error. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Review of the file shows the script you provided was dated December 22, 2020, which was after the date of service and would not validate the claim. Therefore, we decided that the Plan does not have to pay for CPAP device (CPT code E0601) and miscellaneous DME supply or accessory, not otherwise specified (CPT Code A9999) provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an unspecified preventative procedure (D1999) provided on November 23, 2020.

You asked the Plan to pay for the dental services. You say that your provider did not inform you of any out-of-pocket costs you might incur prior to receiving services, and you cannot afford these expenses. The Plan denied your request. The Plan says one comprehensive evaluation, either oral or periodontal, can be covered every three years. The Plan says they paid for a comprehensive periodontal evaluation and therefore the comprehensive oral evaluation is not eligible for coverage as it exceeds the frequency allowed by the Plan's benefit. In addition, the unspecified preventative procedure is not covered by Medicare or by the Plan's supplemental dental 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 or were provided in a frequency that exceeds what is allowed by the Plan. Documentation shows that you had another comprehensive exam within three years. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an unspecified preventative procedure (D1999) provided on November 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient hospital services from January 17, 2019, to January 18, 2019.

You asked the Plan to waive the coinsurance for outpatient hospital services. You say that you cannot afford 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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

You have been asked to pay $1,093.33, which is less than the 20% coinsurance for outpatient hospital services. Outpatient hospital services fall 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 coinsurance for outpatient hospital services from January 17, 2019, to January 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two topical applications of fluoride provided on October 28, 2020, and November 3, 2020.

You asked the Plan to pay for the topical applications of fluoride. You say that the provider you saw is in-network.The Plan denied your request. The Plan says this service is not covered.

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 topical applications of fluoride provided on October 28, 2020, and November 3, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve radiopharmaceutical localization of tumor inflammatory process
for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says that the plan has no contractual obligation to cover services that are not reasonable and
necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found in this case, the enrollee has diuretic responsive edema and an electrocardiogram showing low voltage
and right bundle branch and left anterior fascicular block. An echocardiogram shows left ventricular
hypertrophy but preserved ejection fraction. The documentation provided indicates a concern for cardiac
Amyloidosis based upon the cardiac findings and other symptoms. The requested service is medically
reasonable and necessary, and recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-approve
radiopharmaceutical localization of tumor inflammatory process for the enrollee.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI of the left shoulder.

You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says there is no documentation of issues regarding the left shoulder.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 

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 MRI.Our reviewer says that there is no clinical rationale for the requested MRI of the left shoulder. Our physician reviewer found the physical exam is normal and there is no documentation of any previous x-ray of the shoulder.

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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve the MRI of the left shoulder.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the osteogenesis stimulator (E0760).

You asked the Plan to pay for the osteogenesis stimulator. You say that you would like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says the fracture has not been present for 90 days and there is no documentation of non-union.

The Plan follows Medicare rules. Medicare rules say that an ultrasonic if nonunion of a fracture is documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days.

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 osteogenesis stimulator. Our reviewer says that Medicare's coverage criteria for the bone growth stimulator have not been met. Our physician reviewer found the documentation does not include x-rays taken three months apart showing non-union.

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 osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pay for the osteogenesis stimulator (E0760).
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 you need the rehab in order to be able to walk again and get back to your normal life. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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 pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and confusion and was treated for pneumonia and atrial fibrillation. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on October 29, 2020.

You asked the Plan to waive the copayment for the CT scan. You say that you should not be responsible for the
copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing
amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200
copayment for in-network advanced imaging service (not including x-rays).

You have been asked to pay a $200 copayment for the CT scan. The CT scan falls within the "Outpatient
diagnostic tests and therapeutic services and supplies" 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 the CT scan provided on October 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 9, 2019.

You asked the Plan to pay for the subsequent nursing facility care. You say that you did not receive proper notice of this enrollee's benefit determination which resulted in the untimely submission of the claim. The Plan denied your request. The Plan says this claim was received on October 9, 2020 which is past the allowed 12 month time frame.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the subsequent nursing facility care was not filed until October 9, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services coded S0207 provided on June 16, 2020.

You asked the Plan to pay for the paramedic intercept services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 S0207 is paramedic intercept, non-hospital-based als service (non-voluntary), non-transport.

We find that CPT code S0207 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the paramedic intercept services have not been met. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services coded S0207 provided on June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical placement of mini implant (D6013), extraction, erupted tooth or exposed root (D7140), and bone graft at time of implant placement (D6104) provided September 9, 2020.

You asked the Plan to pay for the mini implant extraction and bone graft. You say that the services should be covered. The Plan denied your request. The Plan says you did not use a network provider and therefore the services are not covered.

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. The Plan covers the mini implant extraction and bone graft when the services are medically necessary and reasonable.

We looked at the file and Medicare rules. You received the dental services from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the mini implant extraction and bone graft have not been met. Therefore, we decided that the Plan does not have to pay for surgical placement of mini implant (D6013), extraction, erupted tooth or exposed root (D7140), and bone graft at time of implant placement (D6104) provided September 9, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on February 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 the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that services rendered to a registered inpatient must be billed with POS code 21. 

We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the date of service at issue. The services were not billed with the required 21 POS code. 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 testing services rendered on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on December 15, 2020.

You asked the Plan to waive the copayment for an eye exam. You say that you feel that your diagnosis of cataracts should not make the eye exam diagnostic and this should still be considered an annual eye exam. 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 $30 copayment for eye exams for vision care. 

You have been asked to pay a $30 copayment for an eye exam. An eye exam falls within the vision 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. Therefore, we decided that the Plan does not have to waive the copayment for an eye exam provided on December 15, 2020.