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

We decided that the Plan does not have to pay for ambulance services (A0425, A0427) provided on October
13, 2020.
You asked the Plan to pay for ambulance services. You say that this was billed with appropriate diagnosis
codes. The Plan denied your request. The Plan says this was not billed with a required diagnosis.
The Plan must follow Medicare rules. Medicare rules say that a secondary diagnosis of Z74.01, Z74.3, Z78.1,
or Z99.89 must be reported for ambulance services.
We looked at the file and Medicare rules. The services at issue were not billed with any of the required
secondary diagnosis codes. Based on this information, we decided that Medicare rules for coverage of
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance
services (A0425, A0427) provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ankle part to a prosthesis (L5968) and a protective covering (L5966).
You asked the Plan to pre-approve the prosthesis components. You say that all of the prothesis components are medically necessary. The Plan denied your request. The Plan says they reviewed the expedited appeal request and rendered a partial uphold decision.
The Plan follows Medicare rules. Medicare rules say that use of L5968, L5982, L5984 or L5986 is based on the beneficiary's K-level modifier (K0-K4), as referenced in the LCD. 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 prosthesis components. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no documentation that supports that the member's activity subjects her prosthesis to harsh environmental situations or that she engages in any extraordinary activities that would justify the need for extra protection with a flexible outer surface covering system (L5966). Protection of prosthetic components can be achieved with the component defined by the code L5705, which has been approved. The protective cover (L5966) is not medically necessary and cannot be covered. The review has determined that the ankle component does not meet the enrollee's K-level Modifier. (Additionally, it does not meet criteria in addition to the approved L5986). The Protective Cover is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prosthesis components have not been met. Therefore, we decided that the Plan does not have to pre-approve an ankle part to a prosthesis (L5968) and a protective covering (L5966).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you require these services because of two previous strokes. The Plan denied your request. The Plan says that your care could be provided at a lower level service at your residence.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of stroke and are living at home with ongoing weakness. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit provided on September 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for a specialist office visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 a specialist office visit provided on September 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the urology services provided on December 14, 2020 by an out of network provider.
You asked the Plan to pay for the urology services. You say that you would like a onetime courtesy to review and overturn the denial. The Plan denied your request. The Plan says you did not provide good cause for why prior authorization was not requested.
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 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 urology services provided on December 14, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 140mg/ml Repatha injections.

You asked the Plan to pre-approve the Repatha. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this medication is not covered under Medicare Part B.

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 140mg/ml Repatha injections.

Benefits for the Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker provided on December 31, 2020, by a provider not enrolled in the Medicare program.

You asked the Plan to pay for a walker. You say that you need the requested item to walk long distances. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a walker provided on December 31, 2020, by a provider not enrolled in the Medicare program.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 6, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatry services provided on January 22, 2021 by an out of network (OON) provider.
You asked the Plan to pay for psychiatry services. You say that you feel like you are being singled out. You say that these services are medically necessary. The Plan denied your request. The Plan says there are in-network providers available. The Plan says that prior authorization was not obtained.
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 psychiatry services provided on January 22, 2021 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided from December 20, 2020, to January 11, 2021.
You asked the Plan to pay for the services provided. You say that no other providers in the area offer the unique therapy. The Plan denied your request. The Plan says this provider type is not eligible in the Medicare program.
The Plan must follow Medicare rules. Medicare rules say that a marriage family therapist is not eligible to participate in Medicare.
We looked at the file and the rules. The records show that you received services from a marriage and family therapist. This type of provider is not covered by Medicare or your plan. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services provided from December 20, 2020, to January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a below knee prosthesis (L5301), test socket (L5620), total contact (L5637), suspension locking mechanism (L5671), custom socket insert (L5673), endoskeletal alignable system (L5910), endoskeletal system ultra-light material (L5940), flexible keel (L5972), multi-axial rotation unit (L5986), external frame (L5645), protective cover (L5704), flex cover system (L5962), and prosthetic sheath (L8400).
You asked the Plan to pre-approve the replacement prosthesis and accessories. You say that a replacement prosthesis is medically necessary as the current one no longer fits. The Plan denied your request. The Plan says the records provided do not support that the replacement prosthesis is medically necessary.
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 replacement prosthesis and
accessories. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found records do not document a change in the physiological condition of the enrollee or irreparable wear of the device or a part of the device. 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 replacement prosthesis and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a below knee prosthesis (L5301), test socket (L5620), total contact (L5637), suspension locking mechanism (L5671), custom socket insert (L5673), endoskeletal alignable system (L5910), endoskeletal system ultra-light material (L5940), flexible keel (L5972), multi-axial rotation unit (L5986), external frame (L5645), protective cover (L5704), flex cover system (L5962), and prosthetic sheath (L8400).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on November 26, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because there is no evidence of an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on November 26, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to issue reimbursement of the copayment for the diagnostic colonoscopy (45378) provided on February 10, 2021.
You asked the Plan to issue reimbursement of the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly to the service provided.
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 if you receive a colonoscopy without previous symptoms, this is considered preventive and there will be no copay or coinsurance. If your doctor is performing the colonoscopy because you have shown symptoms of a medical condition, this is considered outpatient surgery. You must pay a $250 copayment for a surgical service provided at an in-network ambulatory surgical center. You have been asked to pay a $250 copayment for the colonoscopy service provided. Based on the Plan contract however, you cannot be asked to pay this amount for the colorectal screening exam. The record shows that you did not have any signs or symptoms that were the reason for this testing to be performed. Additionally, no polyps were found or removed during this exam performed. Medicare specifically covers this procedure as a screening for those with high risk. Your history of polyps meets the Medicare definition of high risk, meaning that you are eligible for coverage of this procedure as a screening exam. Therefore, we decided that the Plan has to issue reimbursement of the copayment for the diagnostic colonoscopy (45378) provided on February 10, 2021.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health visits on February 3 to March 23, 2021.
You asked the Plan to waive the copayments for outpatient mental health visits. You say that you want a continued copayment waiver like the one that was given in 2020 for reasons related to the COVID-19 pandemic. The Plan denied your request. The Plan says the correct copayment was 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 $40 copayment for each Medicare-covered individual or group visit. You have been asked to pay a $40 copayment for outpatient mental health visits. 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 copayments for outpatient mental health visits on February 3 to March 23, 2021.
Your complaint about the Plan discontinuing its COVID-19 copayment waiver program is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment and related supplies provided from June 5, 2020, to June 30, 2020.
You asked the Plan to pay for the services provided. You say that a corrected physician order and medical records were provided. The Plan denied your request. The Plan says the billed supply codes cannot be verified.
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 physician order or 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 durable medical equipment and related supplies provided from June 5, 2020, to June 30, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services (A0425, A0427) provided January 20, 2021.
You asked the Plan to pay for the ambulance services. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
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 services were medically necessary. Our physician reviewer found given the constellation of symptoms that are concerning for an active infection during a pandemic, it would be medically appropriate to utilize paramedic services for monitoring and transport of this enrollee. Her symptoms made the possibility of dehydration likely. 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 ambulance services (A0425, A0427) provided January 20, 2021.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye procedure provided on September
23, 2020.
You asked the Plan to waive the copayment for the eye procedure. You say that there was no special prep or
observation for this procedure, and you had no idea there would be such a large copayment for surgical
services. You say that the nurse assistant made sure you were not charged a copayment and the charge should
be removed. The Plan denied your request. The Plan says the copayment 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 $250
copayment for each Medicare-covered outpatient hospital facility visit.
You have been asked to pay a $250 copayment for the eye procedure. The eye procedure falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The records show the procedure is considered a surgical service that was billed by
the hospital. 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 eye procedure provided on September
23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, complete series of intraoral x-rays, prophylaxis, and preventive procedure provided on January 28, 2021 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, complete series of intraoral x-rays, prophylaxis, and preventive procedure. The Plan denied your request. The Plan says services rendered by a provider who is not in network are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, complete series of intraoral x-rays, prophylaxis, and preventive procedure provided on January 28, 2021 by an OON provider.