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

We decided that the Plan does not have to pay for air ambulance transportation provided on August 9, 2020.
You asked the Plan to pay for air ambulance. You say that the enrollee required further interventions which were not available locally, so was transported on an emergent basis to the nearest hospital with the service capabilities to treat the enrollee. The Plan denied your request. The Plan says the denial of payment for this service is correct, because Medicare only covers ambulance services to the nearest appropriate medical facility.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if the enrollee's 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. Our reviewer says that this transportation does not meet the Medicare criteria for payment. Our physician reviewer found the documentation does not support that the enrollee suffered from an illness or injury that contraindicated transportation by any means other than ambulance. The documentation does not support that the enrollee's condition was such that the time needed to transport the enrollee by ground, or the instability of transport by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The enrollee ambulated into the aircraft per his request. The enrollee transferred to the ambulance stretcher upon arrival. The documentation does not support that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee, or that the destination hospital was the nearest appropriate facility to treat 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 air ambulance have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance transportation provided on August 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on February 26, 2020.
You asked the Plan to pay for the office visit. You say that this was your established place of treatment. You say that you have been given authorization in the past to see this provider. The Plan denied your request. The Plan says out-of-network services were not authorized.
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 the office visit provided by an out-of-network provider on February 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan services represented by code 71250.
You asked the Plan to pre-approve the CT scan. You say that the clinical documentation provided supports the need for the requested CT scan. The Plan denied your request. The Plan says the clinical information provided does not support the type of CT being requested.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a standard CT is being requested over a low dose CT scan. Our physician reviewer found that the documentation provided did not support that a standard CT scan is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan services represented by code 71250.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 17, 2020. You asked the Plan to pay for the medical services. You say that you believe that these services should be covered. The Plan denied your request. The Plan says this claim denied correctly as the enrollee's hospice became effective October 7, 2020, to January 4, 2021. 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 medical services provided on November 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray equipment set up, chest x-ray, and transportation of portable x-ray equipment and personnel provided on November 5, 2020 by an OON provider.
You asked the Plan to pay for the portable x-ray equipment set up, chest x-ray, and transportation of portable x-ray equipment and personnel. You say that this enrollee was referred to you by a participating provider. The Plan denied your request. The Plan says the enrollee was referred by a non-participating provider. The Plan also says that 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 the portable x-ray equipment set up, chest x-ray, and transportation of portable x-ray equipment and personnel provided on November 5, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from October 5, 2020, to November 9, 2020.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you have never been charged in the past. 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 DME and related supplies. You received DME and related supplies on October 5, 2020. The total allowed amount is $820.80 and 20% of that is $164.16. You received DME and related supplies on November 9, 2020. The total allowed amount is $820.80 and 20% of that is $164.16. The total amount you owe is: $328.32. You have been asked to pay the total coinsurance amount of $328.32 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided from October 5, 2020, to November 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for massage therapy services (97124) provided November 17, 2020 to November 30, 2020.
You asked the Plan to pay for the massage therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says this type of provider is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pay for massage therapy services (97124) provided November 17, 2020 to November 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy services.
You asked the Plan to pre-approve additional physical therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 additional physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had prior therapy. The documentation does not demonstrate that the enrollee's functional level needs the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429, A0425) provided September 17,
2020.
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. 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 services. Our reviewer says
that ambulance transport was not medically necessary. Our physician reviewer found documentation did not
support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a
fully equipped ambulance can provide for safe transport. The record does not show that transport by other
means was contraindicated in this case.
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 services have not been met. Therefore, we decided that the Plan
does not have to pay for ambulance services (A0429, A0425) provided September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 chiropractic visits.
You asked the Plan to pre-approve the 14 chiropractic visits. You say that you would like reconsideration because the adjustments relieve your pain and help you to function. The Plan denied your request. The Plan says this service is not medically reasonable and 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 pre-approve the 14 chiropractic visits. Our reviewer says that there is no evidence that clinical improvement has occurred or that clinical improvement will occur with any additional chiropractic treatments. Our physician reviewer found there is no reason why you cannot perform independent, self-directed, home exercises, for any remaining aches and pains, rather than the continuation of skilled chiropractic intervention. 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 14 chiropractic visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 14 chiropractic visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FDG PET.
You asked the Plan to pre-approve FDG PET. You say that you would like reconsideration because the member appears to have Parkinson's Disease and PET is critical for an evaluation. The Plan denied your request. The Plan says the provider is not differentiating fronto-temporal dementia (FTD) vs. Alzheimer's Dementia (AD).
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 FDG PET. Our reviewer says that the records do not support that the member meets diagnostic criteria for both AD and FTD. Our physician reviewer found the member does not meet NCD criteria for coverage of FGD PET. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of FDG PET have not been met. Therefore, we decided that the Plan does not have to pre-approve FDG PET.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the hand x-ray (CPT code 73130) and hospital outpatient clinic visit for assessment and management of a patient (CPT Code G0463) provided on November 19, 2020, by a non-participating provider.
You asked the Plan to pay for the medical services. You say that you were not told the provider was not in-network. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider and the services were not urgent or emergent, nor were they 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 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 the hand x-ray (CPT code 73130) and hospital outpatient clinic visit for assessment and management of a patient (CPT Code G0463) provided on November 19, 2020, by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99222) provided on June 10, 2019.
You asked the Plan to pay for hospital care. You say that you did not receive information about the enrollee's insurance needed to file this claim timely. The Plan denied your request. The Plan says claims must be filed no more than a year from the date of service.
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 hospital care was not filed until October 6, 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 hospital care (99222) provided on June 10, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for knee orthoses provided on September 12, 2020.
You asked the Plan to pay for knee orthoses. You say that these items were properly billed, and you are appealing with supporting documentation. The Plan denied your request. The Plan says that the denial of payment for these items is correct, because the ordering physician is not included in the enrollee's 12-month history of claims and the enrollee apparently did not receive video or telephonic visit by the ordering physician to warrant the codes billed.
The Plan must follow Medicare rules. Medicare rules say that to justify payment for billed items, a supplier must submit a standard written order, medical records, correct coding, and proof of delivery. We looked at the file and Medicare rules. The records submitted include a standard written order which meets all the necessary criteria, medical records describing the need for the items, support for the codes billed, and proof of delivery. These items are not subject to face-to-face evaluation requirements, and the records submitted do include a telehealth evaluation performed by the ordering physician in which he determined the need for these items. The ordering provider is an in-network provider with the Plan. Therefore, based on the documentation submitted you have met the documentation requirements to support coverage for the items billed. Based on this information, we decided that Medicare rules for coverage of knee orthoses have been met. Therefore, we decided that the Plan has to pay for knee orthoses provided on September 12, 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 surgical extraction provided on November 25, 2020.
You asked the Plan to pay for the extraction. You say that you received a simple extraction. The Plan denied your request. The Plan says surgical extractions are not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The only type of extractions covered under your plan are non-surgical extractions. Therefore, we decided that the Plan does not have to pay for the surgical extraction provided on November 25, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the CTA of the head.
You asked the Plan to pre-approve the CTA of the head. You say that you would like reconsideration because the member has a history of brain trauma and current neurologic symptoms. The Plan denied your request. The Plan says that the member does not meet coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CTA of the head. Our reviewer says that this request for CTA head will be considered medically necessary at this time. Our physician reviewer found this request is appropriate due to the changing symptoms and other tests being inappropriate. 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 CTA of the head have been met. Therefore, we decided that the Plan has to pre-approve the CTA of the head.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroplasty.
You asked the Plan to pre-approve sacroplasty. 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. 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 sacroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational procedure. Therefore, the request is deemed not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroplasty.