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

We decided that the Plan does not have to waive the co-payment for the ambulance ride provided on August 25, 2020.

You asked the Plan to waive the co-payment for the ambulance ride. You say that you were advised the computed tomography (CT) scan was medically necessary and you needed to go by ambulance. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 co-payment for each covered, one-way ambulance trip by ground or water. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $295 co-payment for the ambulance ride.

You have been asked to pay a $212.93 co-payment for the ambulance ride. The ambulance ride falls within the "Ambulance services" 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 co-payment for the ambulance ride provided on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hyperbaric oxygen therapy (99183) provided on December 4,
2020, by an OON provider.

You asked the Plan to pay for hyperbaric oxygen therapy. You say that this was medically necessary. The Plan
denied your request. The Plan says this was 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 hyperbaric oxygen therapy (99183) provided on
December 4, 2020, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).

You asked the Plan to pre-approve SNF care. You say that the enrollee requires more care than his family can provide and is in need of supervision. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on October 14, 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 Place of Service (POS) code 21 must be billed
for services rendered while an enrollee is under inpatient status.

We looked at the file and Medicare rules. The file shows that procedure codes 95938, 95861, 95937 were billed
with POS code 15; however, the enrollee was under inpatient status for the date of service at issue. Therefore,
we decided that the Plan does not have to pay for the testing services rendered on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services.
You asked the Plan to pre-approve dental services. You say that the infections are affecting your heart. The Plan denied your request. The Plan says 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 file shows that a dental crown for tooth #19 was requested. We looked at the file and the rules. You last received a dental crown on May 13, 2021. Your plan only covers 1 crown per calendar year. Based on this information, the Plan's rules for coverage have not been met. The file shows that a core buildup, gingival irrigation, pre-diagnostic testing, and fluoride varnish were requested. Although the Plan offers a dental benefit in excess of Medicare coverage, these requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the requested dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided on January 11, 2021.

You asked the Plan to reimburse you for the limited oral evaluation. You say that extractions are covered up to $200. You say that this allowance should have been applied. The Plan denied your request. The Plan says limited oral evaluation is not listed as 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 limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided on January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (PWC).

You asked the Plan to pre-approve a PWC. You say that this is medically necessary. The Plan denied your request. The Plan says that your request is not medically necessary because the home evaluation is not included in the medical records.

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 a PWC. Our reviewer says that a PWC is not medically reasonable and necessary. You have a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. Your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair due to weakness, lower extremity amputation and unstable gait. You can safely operate a power mobility device. There is no documentation that your home provides adequate access, maneuvering space and surfaces for the operation of a power wheelchair. Our physician reviewer found that your condition does not meet Medicare criteria for a PWC.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PWC have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (PWC).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code 81479) provided to the enrollee on October 12, 2020.

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Review of the file shows that the enrollee had cardiovascular risk assessment testing on October 12, 2020. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code 81479) provided to the enrollee on October 12, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the computed tomography (CT) scan of the heart.

You asked the Plan to pre-approve the CT scan of the heart. You say that this request is medically necessary.
The Plan denied your request. The Plan says that the criteria for the requested CT scan have not been met.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. In this case, we requested additional medical records in order to evaluate the
submitted request. Medical records were not submitted. The Plan did not respond to our request for these
records to indicate that they had made a good faith effort to receive them. Therefore, we decided that the Plan
has to pre-approve the computed tomography (CT) scan of the heart.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nursing and aide services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 the requested services. Our physician reviewer found that there is no documentation that skilled nursing services are required to provide treatment in order to improve your condition, or to establish a maintenance program to maintain your condition or prevent deterioration. The medical notes indicate your medical conditions are stable and your needs appear to be custodial. There is no documentation that home health aide services reasonable and necessary to the treatment of your illness or injury by the skilled professional staff as records do not document any skilled need. 

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health nursing and aide services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the placement of amniotic membrane on the ocular surface (65778) provided on January 29, 2019.

You asked the Plan to pay for the ophthalmic service. You say that there was a system issue and staffing changes that impacted billing on your end. The Plan denied your request. The Plan says this claim was received after 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 ophthalmic service was not filed until January 28, 2021. 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 placement of amniotic membrane on the ocular surface (65778) provided on January 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the facet joint innervation (64635).
You asked the Plan to pre-approve RFA of the facet joint innervation. You say that the requested procedure is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for the requested procedure have not been met
The Plan follows Medicare rules. Medicare rules say that RFA services are subject to the criteria listed 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 RFA of the facet joint innervation. Our reviewer says that the requested service is not medically necessary and reasonable. Our physician reviewer found you are an 81-year-old woman who has chronic low back pain with radiation of the pain to her legs. You have had epidural steroid injections without sustained pain relief. In this case, there is no documentation of the results of 2 sets of diagnostic MBBs as required by the LCD. Therefore, the request is considered 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 RFA of the facet joint innervation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the facet joint innervation (64635).
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 IRF care. The Plan denied your request. The Plan says rules for IRF care have 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 you were admitted to an acute care hospital for respiratory failure and lower extremity cellulitis. Medical conditions 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. Although you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that this patient 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (17000, 15260) provided July 23, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The
Plan denied your request. The Plan says these services have already been paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 17000 & 15260 are not supported in the medical record. Specifically, the record shows
that the claim is a duplicate of claims 820202930316502 and 820210140467104. Based on this information, we
decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that
the Plan does not have to pay for surgical services (17000, 15260) provided July 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automated external defibrillator rental (K0606) provided on November 1, 2020.

You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item provided is not covered under the contractual policy or by Medicare as the enrollee was in an inpatient status at the time of service.

The Plan must follow Medicare rules. Medicare rules say that the DMEPOS benefit is meant only for items a beneficiary is using in his or her home. For a beneficiary in a Part A inpatient stay, an institutional provider is not defined as a beneficiary's home for DMEPOS, and so Medicare does not make separate payment for DMEPOS when a beneficiary is in the institution. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Specifically, the record shows that the enrollee was an inpatient during the date of service at issue. Medicare does not make separate payment for DMEPOS when a beneficiary is in an institution.

The institution is expected to provide all medically necessary DMEPOS during a beneficiary's covered Part A stay. Therefore, we decided that the Plan does not have to pay for the automated external defibrillator rental (K0606) provided on November 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service described by current procedural terminology (CPT) code 85060 provided on November 19, 2020.
You asked the Plan to pay for CPT code 85060. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the professional component of this procedure is only payable for inpatients. The services were billed with an outpatient place of service. Payment for this service cannot be made for hospital outpatients. Based on this information, we decided that Medicare rules for coverage of CPT code 85060 have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory service described by current procedural terminology (CPT) code 85060 provided on November 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits
.
You asked the Plan to pre-approve physical therapy. You say that you need additional physical therapy so you can continue to recover and gain strength and mobility. The Plan denied your request. The Plan says the denial of authorization for additional physical therapy visits is correct, because additional physical therapy visits 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 physical therapy. 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 you have previously been treated with outpatient therapies and should be independent with a home exercise program. These additional therapy services are not an appropriate duration and frequency for your condition and are not medically 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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the apicoectomy - molar (D3425) and the retrograde filling (D3430) received January 4, 2021.

You asked the Plan to pay for the apicoectomy - molar (D3425) and the retrograde filling (D3430). You say that the provider's office told you that you would be covered. The Plan denied your request. The Plan says you have access to the Plan contract, and the requested services are not listed as covered 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 apicoectomy - molar (D3425) and the retrograde filling (D3430) received January 4, 2021.