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

We decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground mileage (A0425) provided on July 17, 2019.
You asked the Plan to pay for the ambulance service. You say that the EOB needs to show full patient responsibility so that you may bill secondary. The Plan denied your request. The Plan says ambulance transportation to a doctor's office is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground mileage (A0425) provided on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit provided on August 8, 2019.You asked the Plan to waive the copayment foran office visit. You say that the provider told you that you would not owe a copayment.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 saysthat you must pay a $0 copayment for office visits provided by a PCMH and a $35 copayment for office visits provided by a non-PCMH.The record shows that you had an office visit with a non-PCMH provider on August 8, 2019. Therefore, you are responsible to pay the $35 copayment.  You have been asked to pay a $35 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora tendon sheath injection provided on August 27, 2019.You asked the Plan to waive the copayment fora tendon sheath injection. You say that you were not informed of the additional charges.The Plan denied your request. The Plan says the claims were processed correctly andyou 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 $175 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received a tendon sheath injection on August 27, 2019. A tendon sheath injection is considered an outpatientsurgical procedure. Therefore, you are responsible to pay the allowed amount of $135, which is less than the $175 copayment. You have been asked to pay $135 for a tendon sheath injection. A tendon sheath injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 fora tendon sheath injection provided on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 21, 2019.
You asked the Plan to pay for the physician's services. You say the provider confirmed that they accepted your
insurance Plan. The Plan denied your request. The Plan says you must receive care from in-network providers
with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if
the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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
physician's services. 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 physician's services provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services provided from September 6, 2019 to September 13, 2019.Youasked the Plan to pay forthe services provided. You say that the plan is inconsistent with reasons to pay for services.The Plan denied your request. The Plan says the procedure code is not valid for Medicare purposes.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 S9328 is Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment.We find that CPT code S9328 is not supported. Specifically, Medicare uses another code for the reporting of, and payment for, these services. 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 forthe home infusion therapy services provided from September 6, 2019 to September 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the ambulance response was medically
necessary. You had an allergic reaction incident and an ambulance was called. You say that you declined
transportation because you had begun to normalize after treatment from the ambulance responders. The Plan
denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on January 26, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the intravenous infusion provided from
April 8, 2019 to April 30, 2019.
You asked the Plan to waive the copayment for the intravenous infusion. You say that you should not be
responsible for the copayment because your doctor recommended you receive the infusions. The Plan denied
your request. The Plan says you have been charged the correct cost sharing 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 $275
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including
but not limited to hospital or other facility charges and physician or surgical charges. For this date of service,
you have been asked to pay the allowed amount of the claim because this amount is less than the $275
copayment for the intravenous infusion.
You have been asked to pay a $173.60 copayment for the intravenous infusion. The intravenous infusion falls
within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and
Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the
intravenous infusion provided from April 8, 2019 to April 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery to remove excess skin (19316, 15833).
You asked the Plan to pre-approve surgery to remove excess skin. You say that the requested services are medically necessary. The Plan denied your request. The Plan says based on the documentation provided, medical necessity has not been established. Therefore, coverage criteria has not been met.
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 surgery to remove excess skin. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedures are considered cosmetic and are not clearly supported to be the cause of urinary tract infections (UTIs) and that skin removal will improve or alleviate the UTIs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgery to remove excess skin have not been met. Therefore, we decided that the Plan does not have to pre-approve surgery to remove excess skin (19316, 15833).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on October 10, 2019.You asked the Plan to waive the copayment forlaboratory tests. You say that the labs were part of an annual wellness visit.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 labs.You received laboratory tests on October 10, 2019. Laboratory tests are not included in the annual wellness exam. Therefore, you are responsible to pay the $35 copayment.  You have been asked to pay a $35 copayment for laboratory tests. Laboratory tests fall within the outpatient diagnostic tests and therapeutic services and supplies 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 forlaboratory tests provided on October 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLotrel 10-20mg Capsules.You asked the Plan to pre-approveLotrel. You say that the medication is medically necessary.The Plan denied your request. The Plan says coverage for Lotrel is not available under the Part B medical benefit.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-approveLotrel 10-20mg Capsules.Benefits for Lotrelmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 7, 2019 by the out of
network provider.
You asked the Plan to pay for wound care. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says no prior authorization was obtained for the services
in question.
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
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 medical services provided on June 7, 2019 by
the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement services coded 14301 and 14302 provided on June 24, 2019.You asked the Plan to pay for the adjacent tissue transfer or rearrangement services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 14301 is Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The CPT Code Manual definition of code 14302 is Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). We find that CPT codes 14301 and 14302 are not supported in the medical record. Specifically, procedure code 14301 is not supported by the medical records submitted. The medical records submitted did not include documentation of an adjacent tissue transfer or rearrangement, any area; defect 30.1sq cm to 60.0sq cm; therefore,this code cannot be verified. Also, 8 units of procedure code 14302 is not supported by the medical records submitted. The medical records did not include documentation of an adjacent tissue transfer or rearrangement, any area; each additional 30.0sqcm, or part thereof (Listed separately in addition to code for primary procedure);therefore,this code cannot be verified.Based on this information, we decided that Medicare rules for coverage of the adjacent tissue transfer or rearrangement services have not been met. Therefore, we decided that the Plan does not have to pay forthe adjacent tissue transfer or rearrangement services coded 14301 and 14302 provided on June 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the Beneficiary.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for aspiration pneumonia in the setting of dysphagia following a brainstem stroke in April of 2019. He was intubated/ventilated and subsequently received a tracheotomy. He has since been weaned from the ventilator during the daytime. He continues to receive ventilator support at night due to ongoing difficult clearing secretions. It is unclear if the enrollee can be fully liberated from the ventilator or safely decannulated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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 long term acute care hospital (LTACH) services for the Beneficiary.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wheelchair accessory, power seat elevation system, any type
(CPT Code E2300) purchased from Numotion on August 23, 2019.
You asked the Plan to pay for the DME. You say that you are requesting reimbursement of services rendered.
The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for wheelchair accessory, power seat elevation system, any type
(CPT Code E2300) purchased from Numotion on August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 13, 2019 by an out of
network provider.
You asked the Plan to pay for the subsequent nursing home visit. You say that you were assigned to the
member at the time of admission and were not made aware of their insurance. The Plan denied your request.
The Plan says the member does not have out-of-network 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 has network providers
available who can provide 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 medical services provided on May 13, 2019 by
out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intravenous tubing extension set (CPT Code S1015) and infection control supplies, not otherwise specified (CPT Code S8301) provided to the enrollee on May 30, 2019.You asked the Plan to pay forthe supplies. You say that the claim should be paid.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of the supplies have not been met. Medicare guidance says procedure code S1015 and S8301 has a status code of "I". You can find this guidance in the 2019 National Physician Fee Schedule Relative Value File July Release.Therefore, we decided that the Plan does not have to pay forintravenous tubing extension set (CPT Code S1015) and infection control supplies, not otherwise specified (CPT Code S8301) provided to the enrollee on May 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oral device/appliance used to reduce upper airway
collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment (CPT Code
E0486) provided to the enrollee on August 19, 2019
You asked the Plan to pay for the oral device. You say that you are a durable medical equipment provider. The
Plan denied your request. The Plan says the provider is a dentist and not currently enrolled as a durable medical
equipment supplier.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the oral device have not been met. Review shows this provider is a
dentist and not currently enrolled as a durable medical equipment supplier. Therefore, we decided that the Plan
does not have to pay for oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable,
custom fabricated, includes fitting and adjustment (CPT Code E0486) provided to the enrollee on
August 19, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee is at risk for deterioration and falls if discharged to a lower level of care.The Plan denied your request. The Plan says there are no medical comorbidities that require a rehab physician, or an interdisciplinary approach to care.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 physician reviewer found that the enrollee's current level of function is transfers with minimal assist, dressing with minimal assist, and ambulation with minimal assist using a rolling walker. The enrollee is medically stable with no evidence of need for supervision by an acute rehab physician, or acute rehab nursingcare. She may benefit from further physical and occupational therapy, but does not require an intensive therapy program. Therefore, an IRF admission is not medically necessary based on her current and prior functional status and medical stability. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.