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

We decided that the Plan does not have to pay forthe ambulance services billed with CPT code A0429 provided on January 10, 2020.You asked the Plan to pay forthe ambulance services. 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 as billed.The Plan must follow Medicare rules. Medicare rules say that in the case where the beneficiary waspronounced dead after the ambulance is called but before the ambulance arrives at the scene: Payment may bemade for a BLS service if a ground vehicle is dispatched or at the fixed wing or rotary wing base rate, asapplicable, if an air ambulance is dispatched. Neither mileage nor a rural adjustment would be paid. Theblended rate amount will otherwise apply. Providers report the A0428 (BLS) HCPCS code.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not theappropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called.Therefore, we decided that the Plan does not have to pay forthe ambulance services billed with CPT code A0429 provided on January 10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to refund the copayment forpodiatry services provided on July 22, 2020.You asked the Plan to refund the copayment forpodiatry services. You say that you are unhappy with the service the physician provided and want to be refunded so you can go and see another physician.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 $35 copayment for podiatry services. You have been asked to pay a $35 copayment for podiatry services. Podiatry services fall within the podiatry 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 refund the copayment forpodiatry services provided on July 22, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea knee orthosis (L1851 and L1852) for the enrollee.You asked the Planto pre-approvethe orthosis. You say that this is medically necessary.The Plandenied your request. The Plansaysthe records show no objective testing for instability, recent surgery, or injury.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 orthosis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that there has been recent injury or surgery to the knee. There is no documentation that there is any knee instability on examination.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof the orthosis have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea knee orthosis (L1851 and L1852) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on May 24, 2020.You asked the Plan to waive the copayment for an ambulance trip. You say that this was a life and death situation. You say that you should not be charged for this. The Plan denied your request. The Plan says the correct copayment has been applied.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 $100 copayment for transportation/ground ambulance. You have been asked to pay a $100 copayment for an ambulance trip. An ambulance trip falls within the transportation/ground ambulance 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 by a participating provider on May 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forbreast tomosynthesis (77062) provided on May 19, 2020.You asked the Plan to payforbreast tomosynthesis. You say that this should be covered.The Plan denied your request. The Plan says this code is not valid.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 code 77062 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of breast tomosynthesis have not been met.Therefore, we decided that the Plan does not have to pay forbreast tomosynthesis (77062) provided on May 19, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortheduplicateoffice visit claim for date of serviceJuly 13, 2020.You asked the Plan to pay forthe duplicate claim for the office visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the provider has confirmed the claim was a duplicate and you are only responsible for the one copayment.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 the claim for a second office visit is a duplicate. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met.Therefore, we decided that the Plan does not have to pay forthe duplicate office visit claim for date of serviceJuly 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital care (99232) received on April 29, 2019.You asked the Plan to pay forhospital care. You say that the claim was submitted timely.The Plandenied your request. The Plan says rules for payment have not been met.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 May 25, 2020. There is insufficient documentation in the record to support that a copy of the claim was filed prior to May 25, 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 forhospital care (99232) received on April 29, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora shower chair.You asked the Plan to pay fora shower chair. You say that the shower chair is necessary.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pay fora shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovepower wheelchair with power tilt (group 3) and related accessories.You asked the Plan to preapprovethe group 3 power wheelchair. You say that the enrollee requires the device due to mobility limitations.The Plan denied your request. The Plan says the enrollee does not have a qualifying condition.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:1. A neurological condition;2. Myopathy; or3. Congenital skeletal deformity.The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.Therefore, we decided that the Plan does not have to preapprovepower wheelchair with power tilt (group 3) and related accessories.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVertiflex superion (Spinal Distraction Devices) (CPT Code(s): 22869, 22870, 77003 and 01992).You asked the Plan to pre-approvetheservices. You say that the services are necessary.The Plan denied your request. The Plan says the services are considered experimental and not covered by Medicare.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 services. Our reviewer says that the requested items/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. Spinal instability is not documented. Hardware not needed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pre-approveVertiflex superion (Spinal Distraction Devices) (CPT Code(s): 22869, 22870, 77003 and 01992).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided by a participating provider on August 3, 2020.You asked the Planto waive the copayment for a diagnostic ultrasound. You say that you were surprised to get a copayment. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for outpatient diagnostic tests/radiological diagnostic services/in-network. You have been asked to pay a $30 copayment for a diagnostic ultrasound. A diagnostic ultrasound falls within the outpatient diagnostic tests/radiological diagnostic services/in-network 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 diagnostic ultrasound provided by a participating provider on August 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 6, 2020 by an OONprovider.You asked the Plan to pay forthe lab services. You say that you should not be penalized for the ordering provider's failure to obtain authorization.The Plan denied your request. The Plan says these services were neither authorized by the Plan nor by a Plan provider.  The ordering provider is an OON provider in addition to the provider of service being an OON provider.  The Plan says that unauthorized, non-plan care is not covered.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 items/services at issue in this appeal. The Plan did not pre-approve the service 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 forthe medical services provided on April 6, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services billed with CPT code A0429 
provided on June 11, 2020. 
 
You asked the Plan to pay for the ambulance services. 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 payable as billed. 
 
The Plan must follow Medicare rules. The rules say in a situation where the beneficiary dies, whether any 
payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is 
pronounced dead by an individual authorized by the State to make such pronouncements. 
 
We looked at the file and Medicare rules. In this case, the file shows that the enrollee's time of death 
pronouncement was after dispatch and before the enrollee was loaded onboard the ambulance. Medicare 
payment is based on the provider's/supplier's BLS base rate, no mileage or rural adjustment is reported, and the 
provider/supplier must use the QL modifier when submitting the claim. In this situation, the correct CPT code 
to bill is A0428 for non-emergency services after assessment. Therefore, we decided that the Plan does not 
have to pay for the ambulance services billed with CPT code A0429 provided on June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed (CPT Code E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that the bed is necessary. The Plan 
denied your request. The Plan says Medicare guidelines state that the height adjustment feature is a 
convenience feature. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it 
must primarily serve a medical purpose. The rules say that a total electric hospital bed (E0265, E0266, E0296, 
and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be 
denied as not reasonable and necessary. 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 the total electric 
hospital bed (CPT Code E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not show a subluxation of spine on an x-ray or an exam. 
 
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.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the only treatment 
allowed by Medicare for chiropractors is to treat a subluxation of the spine. The only submitted spinal imaging 
study is a set of x-rays of the thoracolumbar spine, dated 12/12/16, revealing a convex levoscoliosis, but not 
revealing evidence of a subluxation. Submitted office visit notes, dated 10/26/16, 10/2/18, 10/22/18 10/23/19
and 7/30/20 (telehealth visit) and Integral Medical Services, dated 3/2/17, reveal no spinal musculoskeletal 
findings, and thus, no evidence of subluxation per Medicare guidelines. Therefore, chiropractic treatment is 
neither supported nor allowed per Medicare guidelines.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an interspinous stabilization device for 
the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says nsertion of this device is associated with an unacceptable rate of complications. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee presents with a 20-year history of low back pain and dysfunction. Signs/symptoms are 
consistent with neurogenic claudication. There is imaging evidence of severe neuroforaminal narrowing at the 
right L2/3, bilateral L3/4 and left L4/5 levels. He has failed long-term conservative treatment, including 
activity modification, medications, acupuncture, physical therapy, radiofrequency ablation and epidural steroid 
injections. Under consideration is a request for Vertiflex interspinous device at L4/5. Current evidence based 
medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure 
over the "gold standard" of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed 
outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA 
indications include implantation of the Vertiflex (Superion) device at one or two adjacent lumbar levels in 
patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, 
from L1 to L5. This enrollee has severe spinal stenosis at the L2/3, L3/4 and L4/5, and would not meet FDA 
indications. FDA contraindications scoliosis and osteoporosis, and have not been adequately addressed in the 
medical records. There is imaging evidence of scoliosis of the lumbar spine with no documentation of the Cobb 
angle. There is no discussion indicating that a DEXA scan has demonstrated no osteoporosis in this 66-year-old 
male. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's 
medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and 
necessary for treatment of this enrollee's medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of an interspinous stabilization device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on July 17, 2020, to July 20, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this is a lot of money 
and you cannot afford this. The Plan denied your request. The Plan says the correct copayment has been 
applied. 
 
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 $305 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay $305 copayment per day for days 1-3 for an inpatient hospital stay. The total 
amount you are being asked to pay is $915 ($305 x 3 days = $915). An inpatient hospital stay falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient 
hospital stay provided by a participating provider on July 17, 2020, to July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for travel, meal, and lodging reimbursement provided from July 
16, 2019, to October 1, 2019. 
 
You asked the Plan to pay for travel, meal, and lodging. You say that you are requesting reimbursement as 
these expenses meet the guidelines for coverage of the travel, meal, and lodging benefit. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because these travel, meal, and 
lodging expenses were related to follow-up visits which are not eligible for reimbursement under the TML 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that if a plan chooses to cover transplant services at a 
distant location, the plan must provide reasonable transportation and accommodations for the enrollee and a 
companion. The Plan contract says that travel, meal, and lodging (TML) expense is limited to $10,000 per 
covered transplant and only applies to evaluation and transplant, not to follow-up visits or transplant-related 
inpatient admissions after you receive your transplant. 
 
We looked at the file, Medicare rules, and the Plan's rules. These travel, meal, and lodging expenses were 
related to follow-up visits and therefore are not eligible for reimbursement under the Plan's TML benefit. 
Based on this information, we decided that Medicare rules for coverage of travel, meal, and lodging have not 
been met. Therefore, we decided that the Plan does not have to pay for travel, meal, and lodging reimbursement 
provided from July 16, 2019, to October 1, 2019.