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

We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this service is considered experimental and investigational.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The spacer is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services (99283, 99284)
provided on May 17, 2020.

You asked the Plan to waive the copayment for an emergency department visit. You say that you normally pay
a $5 copayment to have the same services done at your clinic. 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 $90
copayment for emergency care.

You have been asked to pay a $90 copayment for an emergency department visit. An emergency department
visit falls within the emergency care benefit category. Medical records confirm that you were seen in the
emergency department two separate times on May 17, 2020. 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 emergency room services (99283, 99284) provided on May 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services with dental codes D1999, D6057, and D6058.

You asked the Plan to pay for dental codes D1999, D6057, and D6058. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D1999, D6057, and D6058 are not covered under the Plan's supplemental dental benefit.

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, dental codes D1999, D6057, and D6058 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services with dental codes D1999, D6057, and D6058.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99212) electrical stimulation (97014)
provided from August 31, 2020, to September 2, 2020.
You asked the Plan to pay for the chiropractic services. You say that the chiropractor brought your life back to
98% normalcy. Then stopped your appointments, maybe for non-payment. The Plan denied your request. The
Plan says these services are not covered when billed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for outpatient office visit (99212) electrical stimulation (97014) provided from
August 31, 2020, to September 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 22, 2020 to October 1, 2020.
You asked the Plan to pay for home health 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 were not billed correctly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was submitted with a missing/incomplete/invalid/inappropriate place of service. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 22, 2020 to October 1, 2020.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that without these services the patient would not be able to regain full functions and these services are very important in order for him to be discharged safely. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted fora stroke and was treated for aspiration pneumonia. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for precision attachments with dental code D5862.

You asked the Plan to pay for dental code D5862. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D5862 is not covered under the Plan's supplemental dental benefit.

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, dental code D5862 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for precision attachments with dental code D5862.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (K0823).
You asked the Plan to pre-approve the power mobility device. You say that the power mobility device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 the power mobility device. Our reviewer says that the requested mobility device is not medically necessary. Our physician reviewer found documentation indicates that this patient has a personal mobility deficit but it is not clear that this deficit impairs participation in MRADLs in the home. The documentation indicates the patient uses a walker. The documentation is not clear on why the patient's mobility deficit cannot be helped effectively by a walker or manual wheelchair in the home. 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 power mobility device have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (K0823).
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services provided on October 7, 2020.
You asked the Plan to pay for the ambulance services. You say that the ambulance transport provided on October 7, 2020 was medically necessary. The Plan denied your request. The Plan says that the ambulance transport provided on October 7, 2020 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 the ambulance transport provided on October 7, 2020 was medically necessary. Our physician reviewer found based on the documentation provided, the enrollee's residence to the emergency department was medically necessary. The enrollee did require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. Transportation could not have been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. Ambulance services are reasonable for an intoxicated individual complaining of left arm pain, as the individual's history cannot be trusted and the complaint could represent unknown trauma or atypical chest pain. A prudent layperson would believe that immediate medical attention was required for an intoxicated individual with medical complaints. Based on the documentation provided, transportation via ambulance from the street to the emergency department was medically necessary. The enrollee did require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. Transportation could not have been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. Ambulance services are reasonable for an individual who may be intoxicated, may be having a psychiatric episode, may have suffered trauma or may have passed out. A prudent layperson would believe that immediate medical attention was required for someone who was found lying on the ground. 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 been met. Therefore, we decided that the Plan has to pay for the ambulance services provided on October 7, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from December 4, 2017, through December 6, 2017.

You asked the Plan to waive the copayment for inpatient hospital services. You say that you do not understand what the charges are for. The Plan denied your request. The Plan says inpatient hospital services have a $280 copayment per day, for days 1 to 7 days. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $280 copayment per day, for days 1 to 7 days for inpatient hospital services. 

The enrollee has been asked to pay a $560 copayment for 2 days of inpatient hospital care ($280 x 2 days = $560). The services at issue fall within the inpatient hospital services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services provided from December 4, 2017, through December 6, 2017.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you have used all 40 one-way trips for the 2021 benefit year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 40 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the COVID-19 testing received on September 29, 2020.
You asked the Plan to pay for the COVID-19 testing. You say that you were possibly exposed, while out of state, to COVID-19. The Plan denied your request. The Plan says that the testing is not covered in this case.
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 plan has not provided a Medicare-approved source to show that COVID testing should not be covered in this case. Therefore, we decided that the Plan has to pay for the COVID-19 testing received on September 29, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided from June 19, 2020 to July 1, 2020.

You asked the Plan to pay for the chiropractic 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.

The Plan must follow Medicare rules. Medicare rules say that  for Medicare to consider coverage and payment for any item or service, the  information submitted by the supplier or provider must confirm that Medicare  coverage criteria have been met.
 
We looked at the file and Medicare rules. In this case, the medical records provided were insufficient to support the billing of the chiropractor services. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided from June 19, 2020 to July 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the enteral formula (B4152) provided on April 2, 2020.

You asked the Plan to pay for the enteral formula. 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. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the enteral formula (B4152) provided on April 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a PET scan provided on August 13, 2020.

You asked the Plan to pay for the PET scan. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the PET scan. 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 a PET scan provided on August 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on September 8, 2020.

You asked the Plan to pay for the lumbar sacral orthosis. You say that you would like reconsideration because the back brace is medically necessary. The Plan denied your request. The Plan says there are no medical records showing that the prescribing physician ever saw the member.

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 pay for the lumbar sacral orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the member's pain is reduced by restricting mobility of the trunk on an objective physical exam. 

There is no evidence of a recent injury or a recent surgery that requires the brace to facilitate healing. There is no evidence of a deformed spine or weak spinal muscles on an objective physical exam. 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 lumbar sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for interim caries arresting medicament application-per tooth (D1354) adjunctive pre-diagnostic test (D0431) oral hygiene instructions (D1330) provided October 29, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing the denial of the services. This is an extra expense that you do not have the money to pay. The Plan denied your request. The Plan says the services are not covered under the plan 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. The health plan contract on page 105 says that any service not specifically listed in the coverage information is not covered by the plan. 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 interim caries arresting medicament application-per tooth (D1354) adjunctive pre-diagnostic test (D0431) oral hygiene instructions (D1330) provided October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes S1015 and S8301 provided on August 13, 2020.
You asked the Plan to pay for CPT codes S1015 and S8301. 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 providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and Medicare rules. In this case, CPT codes S1015 and S8301 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for CPT codes S1015 and S8301 provided on August 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483).

You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your
request. The Plan says this was not billed with the correct place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The record shows that the service at issue was billed with POS 81 for
an independent laboratory, but the sample was not taken in the laboratory. Based on this information, we
decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing (G0483).