Persius/hicric huggingface dataset:
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 on the date of service you fell and could not get up. You say that your arm is very weak due to the effects of prior treatments and procedures you have had. You stated that you became exhausted and so you called 911. The responders came and helped you up. You stated that since you were not unconscious, bleeding or incoherent, you declined transportation to the emergency room. You say that where you live there is no one that could help you up. 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 October 23, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan.
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
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 a CT scan. Our reviewer says that the
documentation does not support that the requested CT scan is medically reasonable or necessary. Our physician
reviewer found the enrollee has a history of stage IIIB adenocarcinoma of the lung (T4/N2/M0) who has
completed radiation treatment and chemotherapy. The documentation reports no abdominal or pelvic symptoms
or abnormalities on exam. An abdominal/pelvic CT scan from February 24, 2020 showed no acute findings.
Based on the medical records provided and NCCN Guidelines, Non-Small Cell Lung Cancer the follow
abdominal/pelvic CT scan is not medically reasonable and 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 a CT scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve a CT scan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Syringe (J3590).
You asked the Plan to pre-approve Repatha. You say that Repatha is medically necessary. The Plan denied your request. The Plan says this drug is made to be self-administered and is not eligible for coverage 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-approve Repatha Syringe (J3590).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 27, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
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 November 27, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services provided on December 18, 2019.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says that the services were billed with an invalid/missing pick-up zip code.
The Plan must follow Medicare rules. Medicare rules say that that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). We looked at the file and Medicare rules. The documentation submitted by the plan shows a zip code of 93301-2006. The plan has not provided documentation that this zip code is invalid, and therefore, the plans denial cannot be substantiated. Based on this information, we decided that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan has to pay for the ambulance services provided on December 18, 2019.
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 inpatient rehab services provided from February 23, 2018
to March 8, 2018.
You asked the Plan to pay for the services provided. You say that daily rehab nursing care and frequent
physician visits were necessary in order to maximize medical management. The Plan denied your request. The
Plan says authorization was not provided.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
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 services provided. Our physician
reviewer found that the enrollee was at minimal assist for oral hygiene, moderate assist for face washing,
standby assist for upper body dressing, minimal assist for lower body dressing, and minimal assist for toilet
transfers. The provided services were not emergent. The enrollee was already quite mobile at the time of
admission to inpatient rehab. Therefore, the provided services were 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 services provided have not been met. Therefore, we decided that the Plan
does not have to pay for the inpatient rehab services provided from February 23, 2018 to March 8, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve QVAR RediHaler 40mcg (J3535).You asked the Plan to pre-approve QVAR RediHaler 40mcg. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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 QVAR RediHaler 40mcg (J3535).Benefits for QVAR RediHaler 40mcgmay 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip x-ray rendered.
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 not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for an office location; however, the file shows that the services were rendered while the enrollee was inpatient. Therefore, we decided that the Plan does not have to pay for the hip x-ray rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction rendered to you on January 9, 2020.You asked the Plan to pay for these services. You say that you were not aware that the services weren't covered.The Plan denied your request. The Plan says the services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear.Therefore, we decided that the Plan does not have to pay for the eye refraction rendered to you on January 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the services are not medically necessary. Our physician reviewer found additional skilled therapy services are not required to treat your illness or injury, improve your condition, maintain your condition, or prevent deterioration of your condition. You have had prior therapy and reached your functional goals. You are limited by pain. You have been educated on a home exercise program. Ongoing skilled professional therapy services are 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvenasal valve repair (30999).You asked the Plan to pre-approve the nasal valve repair. You say that the services are necessary.The Plan denied your request. The Plan says 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 the nasal valve repair. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation is insufficient to demonstrate that nasal valve repair is medically reasonable and necessary for the enrollee in this case.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 nasal valve repair have not been met.Therefore, we decided that the Plan does not have to pre-approve nasal valve repair (30999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99190 provided on April 24, 2019.You asked the Plan to pay for CPT code 99190. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the enrollee received these services in the facility during an inpatient hospitalization and payment for these services would be included in the Part A-DRG payment to the facility. The plan states payment for these services is the responsibility of the facility.The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment.Therefore, we decided that the Plan does not have to pay for CPT code 99190 provided on April 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bath/shower chair (E0240).
You asked the Plan to pre-approve the shower chair. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says bathtub seats are considered a comfort or convenience item, hygienic equipment and not primarily medical in nature.
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 pre-approve bath/shower chair (E0240).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve24 additional routine transportation trips (A0120). You asked the Plan to pre-approve24 additional routine transportation trips. You say that the requested additional transportation is necessary.The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria has not been met.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve24 additional routine transportation trips (A0120).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe testing services rendered on October 4, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95999 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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the file shows that Train of Four testing was performed and there is a more appropriate code for these services. 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 forthe testing services rendered on October 4, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.You asked the Plan to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.The Plan denied your request. The Plan says you do not meet the criteria established to receive the debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments for 2020.The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning.In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and the Plan's rules. The file shows that your medical conditions are not eligible medical conditions under the Plan's debit card allowance benefit. Therefore, we decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadvanced prosthetic knee features and a rotational unit.You asked the Plan to pre-approvethe prostheticfeatures. You say that the features are medically necessary.The Plan denied your request. The Plan says 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 the prosthetic features. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the knee prosthesis with these advanced features are convenience items and not medically necessary, above standard units.We looked at thisphysician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prosthetic features have not been met.Therefore, we decided that the Plan does not have to pre-approveadvanced prostheticknee features and a rotational unit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient stay October 22 to October 26, 2018.You asked the Plan to waive the copayment for the inpatient stay. You say that the copayment should be waived.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 $300 per day copayment for days 1-5, up to $1,500 per benefit period, for Inpatient Care. You have been asked to pay a $600 copayment,for 2 days of inpatient care, at which point the $1,500 maximum was met for the benefit period. The inpatient stay falls within the Inpatient 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 waive the copayment for an inpatient stay October 22 to October 26, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 26, 2019 by an out of network (OON) provider.You asked the Plan to pay for these services. You say that the process of authorization would take a while so you purchased the item first.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.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 August 26, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transportation services.You asked the Plan to pay forthe transportation services. You say that the wheelchair van transported you to a skilled nursing rehabilitation facility from the hospital and it should be covered.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 wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services.Therefore, we decided that the Plan does not have to pay forthe transportation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for panoramic x-rays (D0330) provided November 6, 2019.You asked the Plan to pay for the dental services. You say that please re-evaluate and process for payment as the last date of service for a full mouth x-ray (D0210) was 09/12/2012.The Plan denied your request. The Plan says the benefit frequency limit has been exceeded.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract says that one set of x-rays is covered per calendar year.  Records show that x-rays were provided on 3/27/19.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 panoramic x-rays (D0330) provided November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bioness functional electrical stimulation (FES).
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. Medicare rules say that FES is covered when specific criteria are met. 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 has a history of weakness secondary to a stroke. The Medicare rules state that FES is only covered to assist in walking after a spinal cord injury. There is no documentation of a history of spinal cord injury and the FES device is being requested for his hand. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Bioness functional electrical stimulation (FES).