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

We decided that the Plan has to pay for the emergency ambulance services (A0427) provided on February 2, 2021.

You asked the Plan to pay for the ambulance services. You say that you were experiencing severe coughing and other symptoms and your partner called your physician, who advised them to call an ambulance. Multiple people arrived on the scene. You were treated and then transported to the hospital where you were quickly admitted. You did not realize that your assessment and transportation were performed by different ambulance crews and did not know that these charges would not be covered. The Plan denied your request. The Plan says that ambulance services are only covered when you are actually transported by ambulance. Because you were not transported by this ambulance, this service is not covered by your Plan.

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 looked at the file and Medicare rules. The Plan denied payment for the ambulance services provided on February 2, 2021, on the basis that there was no transportation provided. According to the narrative provided by the Plan and by yourself, you were treated by one ambulance company and transported by another. The Plan is denying payment for the services provided by the entity that treated you at the scene and did not provide transportation. There is no indication in the file that the Plan verified if there is a contract between the two ambulance providers regarding payment and services. It is possible that these two providers have a contract with each other for accepting payment.

Upon review of the Explanation of Benefits for the billed services in February 2021, it is clear that you were transported to the hospital in some fashion, where you received other medical services on the same date that were billed to the Plan. The transportation was both emergent and necessary from a prudent layperson perspective, and ambulance transportation was recommended by a physician at the time of the call. Furthermore, the only ambulance service at issue in this case, which is also the only ambulance service included on the Explanation of Benefits for the entire month of February, was billed with code A0427. This code is specifically defined as advanced life support ambulance services with emergency transport. Based on the record, there is no proof that you were given any ambulance response/treatment without transport at all.

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 emergency ambulance services (A0427) provided on February 2, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

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 the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee was admitted with shortness of breath and bilateral pulmonary infiltrates from RSV infection. The enrollee was also found to have a right coronary artery occlusion that required intervention. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH 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 enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Invega Sustenna to be dispensed by a pharmacy.
You asked the Plan to pre-approve Invega Sustenna. You say that this drug is needed for your condition. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B when dispensed by a pharmacy and brought to a provider for administration, and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Invega Sustenna to be dispensed by a pharmacy.
Benefits for Invega Sustenna 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from March 15, 2021, through March 17, 2021.
You asked the Plan to pay for the self-administered drugs. You say that these medications were administered by the nurses at your surgeon's instructions. You say that these drugs were never in your possession or self-administered and coverage should not be denied. The Plan denied your request. The Plan says your medical benefit does not cover self-administered drugs.
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 pay for the self-administered drugs provided from March 15, 2021, through March 17, 2021.
Benefits for the self-administered drugs 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: 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 admission to an IRF is necessary for this enrollee.
The Plan denied your request. The Plan says the enrollee does not meet the criteria for IRF admission and
services. The necessary care can be provided in another setting.
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. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee does require physical and occupational therapy, but there is no documented need for an intensive
rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate
in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary
services can be provided in a different level of 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroplasty (0200T).
You asked the Plan to pre-approve sacroplasty. You say that this is the optimal treatment. The Plan denied your request. The Plan says this is experimental.
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 sacroplasty. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found sacroplasty remains experimental for the treatment of sacral insufficiency fractures. More research is needed to show that it is safe and effective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroplasty (0200T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the dental services provided on January 21, 2021 by an OON provider, including the bitewing x-rays (D0274).
You asked the Plan to make additional payment for the dental services including the bitewing x-rays. You say that the bitewing x-ray was a necessary procedure that should be covered by your insurance. The Plan denied your request. The Plan says you last received bitewing x-rays in December 2019 and would not be eligible for more bitewings until December 2021. The Plan also says that the amount of $243.97 is correct because of the bitewing x-rays, and the services were received OON.
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, you are limited to one set of bitewing x-rays (up to four views) every two years. The record shows that you received bitewing x-rays in December of 2019, and your bitewing x-rays benefit has been exhausted. You are also responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to make additional payment for the dental services provided on January 21, 2021 by an OON provider, including the bitewing x-rays (D0274).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of 84 hours of home health aide care per week.

You asked the Plan to pre-approve 84 hours of home health aide care. You say that this care continues to be medically necessary. The Plan denied your request. The Plan says the reduction in services is warranted.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 84 hours of home health aide care. Our
reviewer says that the requested care is not medically necessary and reasonable. Our physician reviewer found the reduction in home health aide hours appears appropriate in this case. Medicare health aide services hours may not exceed the recommended 35 hours per week. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 84 hours of home health aide care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of 84 hours of home health aide care per week.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented pneumatic compression device (PCD) coded as E0652.
You asked the Plan to pre-approve the E0652 PCD. You say that this is the necessary type of PCD for this enrollee. The Plan denied your request. The Plan says the criteria for the E0652 PCD are not met.
The Plan follows Medicare rules. Medicare rules say that an E0652 PCD is covered for enrollees with unique characteristics which contraindicate a standard PCD with lymphedema that extends onto the trunk, chest, or abdomen. 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 E0652 PCD. Our reviewer says that the documentation does not support that coverage criteria for the requested PCD are met. Our physician reviewer found the patient does not have lymphedema of the chest, trunk, or abdomen. The patient does not have unique characteristics that would indicate the segmented pump over a standard pump, and there is no documentation of a trial and failure of the standard pump.
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 E0652 PCD have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmented pneumatic compression device (PCD) coded as E0652.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with single power
option coded as K0856 with related accessories, including a power tilt seating system (E1002).
You asked the Plan to pre-approve the Group 3 PWC with single power option. You say that the requested
PWC is necessary and should be approved. The Plan denied your request. The Plan says the requested type of
PWC base is not covered for this enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC base described by code K0856 is
covered only when the enrollee meets the criteria for a power tilt/recline seating system 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 the Group 3 PWC with single power
option. Our reviewer says that the documentation does not support that the power tilt seating system is
reasonable and necessary, meaning that the Group 3 PWC base being requested is not medically reasonable and
necessary. Our physician reviewer found the documentation indicates the patient has a mobility deficit that
impairs daily living activities in the home and is not ameliorated by a walker, cane, manual wheelchair due to
fatigue and weakness. While the patient may be able to safely operate a PWC, the requested K0856 with
accessories exceeds the patient's medical need.
The documentation does not reveal that the patient is at high risk for development of a pressure ulcer and is
unable to perform a functional weight shift; or utilizes intermittent catheterization for bladder management, or
needs a power seating system to manage increased tone or spasticity. The patient has a Group 3 qualifying
diagnosis but does not require power tilt or recline and does not have a need for a special drive control (head
control, sip and puff, or switch control). Therefore, the request for Group 3 power wheelchair with accessories
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 Group 3 PWC with single power option have not been met. Therefore, we
decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with single power
option coded as K0856 with related accessories, including a power tilt seating system (E1002).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of residual tooth roots.
You asked the Plan to pre-approve these services. You say that your partial dentures will not fit without the procedures. The Plan denied your request. The Plan says the services are not a covered 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. Therefore, we decided that the Plan does not have to pre-approve removal of residual tooth roots.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from January 25, 2021, through January 27, 2021.

You asked the Plan to pay for the hospital services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on January 4, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital services provided from January 25, 2021, through January 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S9338) provided from August 26, 2019, to September 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not payable.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes.
We looked at the file and Medicare rules. Code S9338 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (S9338) provided from August 26, 2019, to September 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of care at a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary and reasonable. The Plan denied your request. The Plan says the rules for SNF care have not been met.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the limited documentation provided you do not have documented skilled nursing needs. In addition, the enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of care at a skilled nursing facility (SNF).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided by a participating provider on February 1, 2021.

You asked the Plan to waive the copayment for emergency room services. You say that no services were performed. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for emergency care. 

The enrollee has been asked to pay a $90 copayment for emergency room services. Once a member signs into an emergency department, an emergency room copayment will be applied, regardless of services being rendered or not. Emergency room services falls within the emergency care 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 emergency room services provided by a participating provider on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - three surfaces, posterior (D2393) received March 11, 2021.

You asked the Plan to pay for the resin-based composite. You say that the Plan should cover the requested service. The Plan denied your request. The Plan says the benefit maximum for this time period has been reached.

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 only covered under this benefit once every 24 months. Your benefit maximum has been reached for this time period. Therefore, we decided that the Plan does not have to pay for the resin-based composite - three surfaces, posterior (D2393) received March 11, 2021.