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

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on February 20, 2019.You asked the Plan to waive the copayment for an ambulance trip. You say that you had no choice in ambulance service.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 $285 copayment for ambulance services. You have been asked to pay the allowed amount of $172.73, which is less than the $285 copayment for an ambulance trip. An ambulance trip 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 copayment for an ambulance trip provided on February 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion or replacement of a neurostimulator system for treatment of central sleep apnea (0424T).You asked the Plan to pre-approve insertion or replacement of a neurostimulator system for treatment of central sleep apnea. You say that the item is necessary.The Plan denied your request. The Plan says the requested item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that it is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion or replacement of a neurostimulator system for treatment of central sleep apnea have not been met.Therefore, we decided that the Plan does not have to pre-approve insertion or replacement of a neurostimulator system for treatment of central sleep apnea (0424T)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner.
You asked the Plan to pre-approve a recliner. You say that the enrollee sleeps well in a recliner and the recliner is breaking down and not comfortable. The Plan denied your request. The Plan says a recliner is not used to treat a medical condition.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a recliner.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management (99239) provided on October 13, 2019.
You asked the Plan to pay for discharge day management. You say that this should be covered. The Plan denied your request. The Plan says this code is not supported.
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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, this code is for 31 minutes or more of discharge day management services. The records do not document the time spent on these services, so this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for discharge day management (99239) provided on October 13, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services rendered on October 14, 2019.
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 that the provider type is not payable by Medicare.
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. The file shows that the services were rendered by a registered nurse (RN). The Plan states that the provider type is not covered; however, the Plan has not provided any documentation or Medicare rules to support that the services are not payable when performed by an RN. Therefore, we decided that the Plan has to pay for the services rendered on October 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve Eliquis tab 5mgYou asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says the medication falls under Part D coverage, which the enrollee does not have.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Eliquis tab 5mg
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral soft tissue (D7286) provided on December 19, 2019.
You asked the Plan to pay for the dental service. You say that the dental service was medically necessary. The Plan denied your request. The Plan says incisional biopsy of oral soft tissue is 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 incisional biopsy of oral tissue is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the incisional biopsy of oral soft tissue (D7286) provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on December 17, 2019.You asked the Plan to waive the copayment for these services. You say that this was an annual visit and should have no copayment.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 $45 copayment for each covered visit or consultation in an outpatient location with a specialist. Review of the file shows that you received specialist services on December 17, 2019. The services fall outside of the scope of an annual preventive gynecological exam. You have been asked to pay a $45 copayment for these services. These services fall within the covered visit or consultation in an outpatient location with a specialist 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 specialist services rendered on December 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 16,
2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Healthcare Common Procedure Coding System (HCPCS) G0480 (1 Unit) remains not supported
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be
covered.
The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of
the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing
services provided to the enrollee on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 20, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on December 20, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent hospital care provided on January 14, 2020.You asked the Plan to pay forthe physician services. You say that the enrollee was not enrolled in hospice at the time the services were rendered.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day ofthe month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on January 8, 2020. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not haveto pay forthe subsequent hospital care provided on January 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869).You asked the Plan to pre-approvethe insertion of interlaminar/interspinous process stabilization/distraction device. You say that this is medically necessary.The Plan denied your request. The Plan says this is experimental.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy.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 insertion of interlaminar/interspinous process stabilization/distraction device. have not been met.Therefore, we decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora flu shot provided out of network on November 12, 2019.You asked the Plan to pay for out of network providers. You say that this flu shot should be covered by the Plan.The Plan denied your request. The Plan says you did not have prior authorization for out of network care.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 has network providers available who can provide a flu shot. The Plan did not pre-approve a flu shot out of network. We found no exception that would require the Plan to pay for this flu shot. Therefore, we decided that the Plan does not have to pay fora flu shot provided out of network on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the items are necessary. The Plan denied your request. The Plan says these items are not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0480 provided on December 10, 2019.You asked the Plan to pay forthe drug testing. 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 supported by the documentation.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 G0480 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed.We find that CPT code G0480 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of interpretation results of confirmatory drug testing.Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded G0480 provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 95861, 95865, 95868, and 95999 provided on May 15, 2019.
You asked the Plan to pay for CPT codes 95861, 95865, 95868, and 95999. You say that the medical records support the billing of CPT codes 95861, 95865, 95868, and 95999. The Plan denied your request. The Plan says the medical records do not support the billing of CPT codes 95861, 95865, 95868, and 95999.
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 95861 is Needle electromyography; 2 extremities with or without related paraspinal areas. The CPT Code Manual definition of code 95865 is Needle electromyography; larynx. The CPT Code Manual definition of code 95868 is Needle electromyography; cranial nerve supplied muscles, bilateral. The CPT Code Manual definition of code 95999 is Unlisted neurological or neuromuscular diagnostic procedure. 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 CPT code 95861, 95865, 95868, 95999. Our reviewer says that the medical records do not support the billing of CPT codes 95861, 95865, 95868, and 95999. Our physician reviewer found for 3 of the codes in question, the records provided for review are not sufficient to make a determination that the requirements of the CPT code have been satisfied. The CPT codes under review all make reference to the performance of Needle electromyography. The records provided for review were limited to the professional interpretation of the IONM report. There was no indication in the report that needles (as opposed to other recording modalities) were used for the recordings under review in this case. In as much it cannot be determined that the requirements for the use of the CPT codes under review were
satisfied. Thus criteria for coverage were not met. Furthermore, we find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 95861, 95865, 95868, 95999 have not been met. Therefore, we decided that the Plan does not have to pay for CPT codes 95861, 95865, 95868, and 95999 provided on May 15, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 30, 2019 to July 2, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary.The Plan denied your request. The Plan says that the enrollee could have been treated in observation.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department on June 30, 2019 after a syncopal episode. He was evaluated and felt to have had hypotension or volume depletion. He was treated with fluids and admitted to telemetry. The following day he had atrial fibrillation requiring Metoprolol. He also had urinary retention and was evaluated by Urology. A Foley was inserted; his medical regimen was adjusted and he was discharged home with outpatient follow-up when considered medically stable on July 2, 2019. The review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 30, 2019 to July 2, 2019.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 progressive lenses (V2781), polycarbonate lenses (V2784), and photochromaticlens tint (V2744) provided on January 16, 2020.You asked the Plan to pay for progressive lenses, polycarbonate lenses, and photochromatic lens tint. You say that you should be reimbursed for the $200 vision allowance.The Plan denied your request. The Plan says the items you received are not covered.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers standard lenses. Additional options includingtinting, polycarbonate, anti-reflective coating are not covered.We looked at the file and the Plan's rules. The upgraded lenses you received are not a covered benefit under the Plan rules.Based on this information, we decided that the Plan's rules for coverage of progressive lenses, polycarbonate lenses, and photochromatic lens tint have not been met.Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781), polycarbonate lenses (V2784), and photochromatic lens tint (V2744) provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown and core buildup, including any pins when
required provided on January 8, 2020.
You asked the Plan to pay for the crown and core buildup. You say that the enrollee received a
predetermination saying the procedure would be covered. You also say that the enrollee was not informed of
the Plan's dental coverage changes that went into effect on January 1, 2020. The Plan denied your request. The
Plan says these services are not covered under the enrollee's contract under any normal circumstances.
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 record also shows that the Plan sent an Annual Notice of Changes
for 2020 to the enrollee in the fall of 2019. Therefore, we decided that the Plan does not have to pay for the
crown and core buildup, including any pins when required provided on January 8, 2020.