Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided on July 29, 2020 by an out
of network (OON) provider.

You asked the Plan to pay for ophthalmology services. You say that you would like this claim reprocessed and
paid. The Plan denied your request. The Plan says prior authorization was not obtained.

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 had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for ophthalmology services provided on July 29, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided July 20, 2020.

You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the services billed.

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 97110 is Therapeutic procedure, 1 or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the record shows the
services were provided in the home health setting. There is a more appropriate CPT code to bill for these
services (G0157). Based on this information, we decided that Medicare rules for coverage of the therapy
services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided July 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the face mask interface, replacement for full face mask, each (A7031 x 3) rendered by the out of network (OON) provider on January 27, 2021.

You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue.

We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the face mask interface, replacement for full face mask, each (A7031 x 3) rendered by the out of network (OON) provider on January 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the myocardial perfusion imaging services coded 78453 provided on January 11, 2021.

You asked the Plan to pay for the myocardial perfusion imaging services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

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 78453 is myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic).

We find that CPT code 78453 is not supported in the medical record. Specifically, the claim was billed with an inappropriate place of service 22 (outpatient). According to claims history, the enrollee was inpatient during this date of service. this means that these services were billed with an inappropriate place of service. Based on this information, we decided that Medicare rules for coverage of the myocardial perfusion imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the myocardial perfusion imaging services coded 78453 provided on January 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425), provided on December 1, 2020.

You asked the Plan to pay for the ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). The Plan denied your request. The Plan says the ambulance transport was not medically necessary.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 

We 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 ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). Our reviewer says that the ambulance transport was not medically reasonable or necessary. Our physician reviewer found that the enrollee is a 65-year-old female that had abdominal pain for 4 days with diarrhea for 2 days. She was evaluated by emergency medical services (EMS) and transported on a stretcher. She was not hypoxic and was alert and sitting in chair. The enrollee's presenting symptoms did not meet the prudent layperson's criteria for emergency care. Outpatient care would have been reasonable. The is no indication of other means of transport such as a wheelchair van or private care that would have been contraindicated for this enrollee. The documentation does not support that the enrollee required expertise or special equipment during the transportation as the enrollee did not require oxygen or immediate treatments. The documentation does not sufficiently support that ambulance transport was medically reasonable or necessary for the enrollee. 

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 ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425), provided on December 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 21, 2020.

You asked the Plan to pay for the ambulance services. You say that you did not ride in the ambulance because of Covid. 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 December 21, 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 December 21, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for services of a physical therapist in home
health or hospice settings, each 15 minutes (G0151) provided on January 4, 2021, and January 6, 2021.

You asked the Plan to waive the copayment for home health services. You say that the cost share is incorrect.
The Plan denied your request. The Plan says the cost share was applied correctly.

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 home health services are covered after the Plan's $300 deductible is met.

The item or service you asked the Plan to waive the copayment for falls within the benefit category home
health agency care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a
$300 deductible before in network Medicare services are covered. This cost sharing is a contractual obligation
that had not been met at the time home health services was received on January 4, 2021 to January 6, 2021.
Therefore, we decided that the Plan does not have to waive the copayment for services of a physical therapist in
home health or hospice settings, each 15 minutes (G0151) provided on January 4, 2021, and January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cognitive assessment and care plan services (99843)
provided January 5, 2021.

You asked the Plan to pay for cognitive assessment and care plan services. You say that you don't understand
why Medicare always covered the services prior to January 1, 2021. These services are important to you being
able to move and they are less expensive than going to a physical therapist or medical doctor. The Plan denied
your request. The Plan says this service is not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for cognitive assessment and care plan services (99843) provided January 5,
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 12, 2020.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 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 November 12, 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 November 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency wheelchair van transport (A0130) provided on December 11, 2020.

You asked the Plan to pay for the transportation service. You say that this transport was medically necessary. The Plan denied your request. The Plan says wheelchair van transport is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. 

The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the non-emergency wheelchair van transport (A0130) provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
January 6, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.

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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 6, 2021.
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 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 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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.

The enrollee does 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit and laboratory services provided by
an out-of-network provider on January 25, 2021.

You asked the Plan to pay for the outpatient clinic visit and laboratory services. You say that the patient was
seen as a new patient due to relocating. You say that the claim should be reviewed for medical necessity. The
Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services
were not approved in advance.

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
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the outpatient clinic visit and laboratory services
provided by an out-of-network provider on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a trigger point injection provided on January 27, 2021.

You asked the Plan to waive the copayment for a trigger point injection. You say that you received the injection at a doctors office and 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 $175 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

The record shows that you received a trigger point injection at an outpatient hospital facility on January 27, 2021. Therefore, you are responsible to pay the $175 copayment.

You have been asked to pay a $175 copayment for a trigger point injection. A trigger point injection 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 trigger point injection provided on January 27, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services (A0429 and A0425) provided on August 21, 2020.

You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says that no additional payment may be made.

The Plan must follow Medicare rules. The rules state that Medicare rules say that Medicare secondary payment
is the lowest of the three stated amounts.

We looked at the file and Medicare rules. According to Medicare rules, secondary payment is the lowest of the
following: (1) The actual charge by the supplier (or the amount the supplier is obligated to accept as payment in
full if that is less than the charges) minus the amount paid by the primary payer; (2) The amount that Medicare
would pay if the services were not covered by a primary payer; (3) The higher of the Medicare fee schedule,
Medicare reasonable charge, or other amount which would be payable under Medicare (without regard to any
applicable Medicare deductible or coinsurance amounts) or the primary payer's allowable charge (without
regard to any deductible or co-insurance imposed by the policy or plan) minus the amount actually paid by the
primary payer.

In this case, the amount correlating to condition (1) is $142.

The amount correlating to condition (2) is $163.

The amount correlating to condition (3) is $142.

As the lowest of these amounts is $142, payment in this amount must be made. Based on this information, we find that Medicare criteria for coverage have been met. Therefore, we decided that the Plan has to pay for ambulance services (A0429 and A0425) provided on August 21, 2020.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation - per quadrant (D4921) and unspecified preventative procedure, by report (D1999) provided September 30, 2020.

You asked the Plan to pay for the gingival irrigation and unspecified preventative procedure. You say that you would like the Plan to provide a one-time exception to cover the services. The Plan denied your request. The Plan says these services are not covered under your dental benefits.

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 gingival irrigation - per quadrant (D4921) and unspecified preventative procedure, by report (D1999) provided September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for debridement of the mastoid cavity (69220)
provided on September 22, 2020, and ophthalmic biometry (92136) provided on December 11, 2020.

You asked the Plan to waive the copayments for the debridement and ophthalmic biometry. You say that you
want reimbursement on your out-of-pocket costs for the 2020 year. The Plan denied your request. The Plan
says your copayments were applied correctly. A copayment is your share of the cost for services and will not
be reimbursed.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for services received from a specialist physician.

You have been asked to pay a $40 copayment for the debridement and ophthalmic biometry. These services fall
within the services received from a specialist 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 copayments for debridement of the mastoid cavity (69220) provided on September 22, 2020, and
ophthalmic biometry (92136) provided on December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a platform crutch.

You asked the Plan to pre-approve Crutch substitute, lower leg platform, with or without wheels, each (E0118). You say that you need this type of walker. The Plan denied your request. The Plan says platform crutches are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The DME MAC medical directors have reviewed information about the products billed using this code. The determination is that there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for these products. There is no physician order or face-to-face documentation in the file. Based on this information, we decided that Medicare rules for coverage of Crutch substitute, lower leg platform, with or without wheels, each (E0118) have not been met. Therefore, we decided that the Plan does not have to pre-approve a platform crutch.