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

We decided that the Plan does not have to pay for the ambulance transportation to your physician's office.

You asked the Plan to pay for the ambulance transportation to your physician's office. You say that you have had to cancel five appointments with your doctor because you do not have transportation to their office. The Plan denied your request. The Plan says there is no documented clinical evidence of medical urgency for ambulance transportation.

Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 transportation to your physician's office. Our reviewer says that there is no documentation that you are unable to get out of bed unassisted, unable to ambulate, and unable to sit in a chair or wheelchair. While you are noted to be on oxygen, there is no documentation of why you cannot travel using portable oxygen, rather than in an ambulance with oxygen. As such, the use of an ambulance for non-emergency transportation is not shown to be medically necessary or reasonable. 

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 transportation to your physician's office have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation to your physician's office.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approved an additional five (5) PT visits.
You asked the Plan to pre-approved an additional five (5) PT visits. The Plan denied your request. The Plan says additional PT 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-approved an additional five (5) PT visits. 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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional five (5) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approved an additional five (5) PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of abscess (D7510) and cone beam CT capture and interpretation (D0365) provided on December 29, 2020.
You asked the Plan to pay for the incision and drainage of abscess and cone beam CT capture and interpretation. You say that you thought these services would be covered. The Plan denied your request. The Plan says these services are not covered by the Plan.
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 incision and drainage of abscess (D7510) and cone beam CT capture and interpretation (D0365) provided on December 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you no longer require daily skilled services.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that your polyneuropathy has caused numbness in your
feet. The Plan denied your request. The Plan says this item is 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.
The records do not show that you 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 pay for foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the acute inpatient hospital services provided August 27, 2020, to August 30, 2020.

You asked the Plan to adjust the cost share for the acute inpatient hospital services. You say that your copayment has processed incorrectly, and you would like this adjusted. The Plan denied your request. The Plan says the copayment has processed correctly, and no reimbursement is due.

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 $300 copayment each day for days 1 to 6 for Inpatient Hospital Care. 

You have been asked to pay a total cost share of $900 for the acute inpatient hospital services ($300 copayment x 3 days). These services fall 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 adjust the cost share for the acute inpatient hospital services provided August 27, 2020, to August 30, 2020.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the home health services provided from September 8, 2020, to October 12, 2020.

You asked the Plan to pay for the home health services. You say that corrected claims with TOB 0327 and 30-day episodes of care were submitted. The Plan denied your request. The Plan says that the corrected claims also denied due to missing information.

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 original claims for the services provided during this time period were correctly denied due to an invalid Type of Bill (TOB) being reported. However, included in the case file, are two corrected claims which have the valid TOB of 0327 which indicates that the claim is a replacement of a prior claim. The file shows that these two corrected claims were also denied for unspecified missing information.

We reviewed the corrected claims and find no obvious deficiencies. These claims were billed for valid episodes of care, with a valid Health Insurance Prospective Payment System (HIPPS) code and included required value codes and the necessary Q-code. Without a specific argument to justify that these claims were not correctly billed, we find that the denial is not supported. Therefore, we decided that the Plan has to pay for the home health services provided from September 8, 2020, to October 12, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) clinician services (G8427) and pain assessment (G8730) provided on September 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider did not obtain prior authorization as is required by Plan benefits.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (99204) clinician services (G8427) and pain assessment (G8730) provided on September 30, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued continuous positive airway pressure (CPAP)
use.

You asked the Plan to pre-approve continued CPAP use. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested services.

The Plan must follow Medicare rules. Medicare rules say that continued CPAP use is only covered for certain
indications.

We looked at the file and Medicare rules. Objective evidence of adherence to use of the PAP device, reviewed
by the treating practitioner must be documented. Adherence to therapy is defined as use of PAP greater than or
equal to 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first
three (3) months of initial usage. Review of the file shows that you only used the CPAP more than or equal to 4
hours per night for 8 days, equaling 27% adherence. Based on this information, we decided that Medicare rules
for coverage of continued CPAP use. have not been met. Therefore, we decided that the Plan does not have to
pre-approve continued continuous positive airway pressure (CPAP) use.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the detection test by nucleic acid for Chlamydia pneumoniae, detection test by nucleic acid for Mycoplasma pneumoniae, detection test by nucleic acid for multiple types of respiratory virus, amplified DNA or RNA probe detection of severe acute respiratory syndrome Covid-19 antigen, and detection test by nucleic acid for organism provided on December 3, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like this claim to be reconsidered and reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the detection test by nucleic acid for Chlamydia pneumoniae, detection test by nucleic acid for Mycoplasma pneumoniae, detection test by nucleic acid for multiple types of respiratory virus, amplified DNA or RNA probe detection of severe acute respiratory syndrome Covid-19 antigen, and detection test by nucleic acid for organism provided on December 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an eight (8) OT visits.
You asked the Plan to pre-approve the additional OT visits. The Plan denied your request. The Plan says an additional eight (8) OT visits are not reasonable and 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 an additional eight (8) OT visits. 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 that the enrollee is a 71-year-old male with pain in his right shoulder after rotator cuff repair, who has been receiving skilled OT intervention in conjunction with a home exercise program as appropriate. The Plan notes that the enrollee has had twenty-four (24) OT visits thus far. The Plan has approved four (4) additional OT visits to finalize a home exercise program, and to educate and reinforce the importance of continued adherence to the program post discharge. OT is generally accepted as specific and effective therapy for the enrollee's condition. The documentation does not support that eight (8) additional OT visits are required to safely and effectively provide treatment for the enrollee in this case. The documentation does not support that the requested services are part of a maintenance program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional eight (8) OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional eight (8) OT visits.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services provided on August 11, 2020.

You asked the Plan to pay for the personal care services. You say that the enrollee switched coverage and the facility was not notified. The Plan denied your request. The Plan says prior authorization was not obtained.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the personal care services provided on August 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional physical therapy (PT) visits.

You asked the Plan to pre-approve ten (10) additional PT visits. You say that the enrollee would benefit from continuation of Aquatic & land physical therapy as she has shown notable improvements. The physical therapy provides the enrollee with an opportunity to increase function with ADLS and minimize pain complaints. The Plan denied your request. The Plan says additional PT is 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 ten (10) additional PT visits. 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 that the enrollee is a 33-year-old woman with a history of hypermobile Ehlers Danlos Syndrome and chronic low back pain, for whom continuation of physical therapy services has been requested. The case file contains a PT progress note dated April 8, 2021, at which time the enrollee reported low back and right lower extremity pain that were persistent but variable by day. Physical therapy may be generally accepted as specific and effective therapy for the enrollee's condition. The available records are insufficient to demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment for the enrollee in this case. The documentation does not demonstrate that the requested services are part of a maintenance program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (D3320) received December 5, 2020.

You asked the Plan to pay for the endodontic therapy. You say that you were told by your provider that this procedure would be covered by your insurance. The Plan denied your request. The Plan says the requested procedure is not covered under your supplemental 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, the requested items or services are not among those covered under this benefit. Your contract with the Plan has a specific list of covered items and services, found on pages 4-72 through 4-81 of the Plan's 2020 Evidence of Coverage. The requested procedure is not on the list of covered procedures. Therefore, we decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (D3320) received December 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the contrast material rendered on September 24, 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 procedure code Q9967 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 Q9967 is low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml. 

We find that CPT code Q9967 is not supported in the medical record. Specifically, there is no documentation of the concentration of Isovue administered. 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 pay for the contrast material rendered on September 24, 2020.