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

We decided that the Plan has to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on January 11, 2021.

You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says that the enrollee could have been safely transported by another type of motor vehicle, possibly a van transport vehicle.

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 ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). Our reviewer says that the ambulance transport was medically necessary. Our physician reviewer found that the enrollee has chronic obstructive pulmonary disease and is on home oxygen. The enrollee activates emergency medical services due to three days of shortness of breath. The record indicates that upon arrival, the enrollee's oxygen saturations were in the mid 80's. A prudent layperson with oxygen dependent chronic obstructive pulmonary disease would believe that three days of increased shortness of breath without immediate medical attention would be cause serious jeopardy to his or her health. The elements of the coverage rules are satisfied. The requested service is recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) have been met. Therefore, we decided that the Plan has to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on January 11, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the root canal (D3330) for tooth # 3.
You asked the Plan to pre-approve the dental service. You say that you thought this service was covered from the beginning. You say that you did not know it was not covered until you sat in the chair. You also say that you do not understand why the root canal is not covered but a crown is. The Plan denied your request. The Plan says root canal is not a covered service.
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 root canal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the root canal (D3330) for tooth # 3.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the preferred Viscosupplemental  are Orthovisc and Monovisc, which do not require authorization.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed Viscosupplemental  treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Synvisc is not approved as step criteria is not met.

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Synvisc injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the request for LTACH care is medically necessary. The Plan denied your request. The Plan says at this time, the enrollee is receiving the appropriate care in the current environment.
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. Our physician reviewer found that the patient is currently undergoing treatment at an acute care hospital (ACH) for COVID-19. The enrollee was intubated/ventilated. The enrollee has only recently started weaning attempts. There is no evidence that the enrollee requires services that are not currently available. 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. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs.
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and the unspecified preventive service (D1999) provided on December 11, 2020.

You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that the frequency limit has been exceeded. The Plan also says that unspecified preventive service is not listed as a covered service.

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 a comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on October 4, 2019. Additionally, the unspecified preventive service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and the unspecified preventive service (D1999) provided on December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for removal of residual tooth roots (D7250
x2), and fillings (D2332 x2) provided on February 2, 2021.

You asked the Plan to pay an additional amount for removal of residual tooth roots, and fillings. You say that
you want the Plan to pay an additional amount for the services at issue. The Plan denied your request. The Plan
says the claims for these services were processed correctly with the applicable out-of-network allowable
amount paid.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of removal of residual tooth roots, and fillings have not been met. Specifically, the allowed amount of
these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is
your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount
for removal of residual tooth roots (D7250 x2), and fillings (D2332 x2) provided on February 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic colonoscopy (45380) provided on December 22, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the diagnostic services. You say that you spoke with a Plan representative before the procedure was done and was told that authorization is not required so you should not be penalized for not having obtained the authorization. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 diagnostic colonoscopy (45380) provided on December 22, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on October 30, 2020.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says eye refractions are not a covered benefit.

The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. 

We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasounds nor waive the copayment for the chiropractic services provided from January 4, 2021, to February 17, 2021.

You asked the Plan to pay for the ultrasounds and waive the copayment for the chiropractic services. You say that the Plan should pay for all the claims because you were told they were covered. The Plan denied your request. The Plan says ultrasound received from a chiropractor is not a covered service and you were charged the copayments 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 $20 copayment for Chiropractic Services. 

You have been asked to pay a $20 copayment for each of the chiropractic services. The chiropractic services fall within the Chiropractic Services 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. The ultrasounds are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the ultrasounds nor waive the copayment for the chiropractic services provided from January 4, 2021, to February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on October 14, 2020.

You asked the Plan to pay for critical care services. You say that this was billed correctly. The Plan denied
your request. The Plan says the billed code is not supported in the records.

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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent on critical
care is not documented in the submitted medical records. Based on this information, we decided that Medicare
rules for coverage of critical care services have not been met. Therefore, we decided that the Plan does not have
to pay for critical care services (99291) provided on October 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ambien tab 10mg.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says this is denied as a benefit exclusion.

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 Ambien tab 10mg.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits rendered on January 4, 2021 and January 11, 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 claims were 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 file shows that the claims were billed with POS code 12 for the home setting, which is not appropriate for the office visit codes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the office visits rendered on January 4, 2021 and January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).

You asked the Plan to pre-approve a power seat elevation feature. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is never covered as it does not serve a primary medical purpose.

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 a power seat elevation feature (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for first hour of prolonged evaluation and management service before and/or after direct patient care (99358) and prolonged evaluation and management service before and/or after direct patient care, each additional 30 minutes (list separately in addition to code for prolonged service) (99359) provided on February 13, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the prolonged services. You say that the doctor should be paid for this service rendered as medical necessity to educate the enrollee on the results of her sleep study interpretation. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 first hour of prolonged evaluation and management service before and/or after direct patient care (99358) and prolonged evaluation and management service before and/or after direct patient care, each additional 30 minutes (list separately in addition to code for prolonged service) (99359) provided on February 13, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for out-of-pocket expenses from January 7, 2020, through December 13, 2020.

You asked the Plan to reimburse you for the out-of-pocket expenses. The Plan denied your request. The Plan says the Plan did not include the Flex Benefit effective January 1, 2020.

The Plan must follow Medicare rules. Medicare says that a supplemental benefit is an item or service not covered by original Medicare, that is primarily health related and for which the MA plan must incur a non-zero direct medical cost.

We looked at the file, the Medicare rules and the Plan's rules. The file shows that the Plan did not provide a supplemental benefit for the Flex Benefit. Therefore, we decided that the Plan does not have to reimburse you for out-of-pocket expenses from January 7, 2020, through December 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on February 21, 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. Medicare rules say that inpatient claims must be billed with Place of Service (POS) code 21. 

We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status during the date of service at issue and the claim was not billed with the required POS code 21. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on February 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT).

You asked the Plan to pre-approve IMRT. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 IMRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found IMRT would not be furnished in accordance with accepted standards of medical practice. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and sleeve provided to the enrollee on March 25, 2021.

You asked the Plan to pay for these services. You say that this should be covered by the Plan. The Plan denied your request. The Plan says that they were unable to discover any evidence of an established relationship between the member and the ordering physician.

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 relevant medical records which support medical necessity for the supplies provided in this case. 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 knee orthosis and sleeve provided to the enrollee on March 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from December 1, 2020, to January 7, 2021.

You asked the Plan to waive the copayment for a SNF stay. You say that you were kept longer due to COVID-19 and were never told that you would owe any kind of 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 says that you must pay a $0 copayment for days 1-20, and a $150 copayment for days 21-100 for SNF care. 

You had a SNF stay from December 1, 2020, to January 7, 2021. Therefore, you are responsible to pay a $150 copayment for days 21-58. However, you are only being asked to pay $2,128.57, which is less than the total copayment amount. 

You have been asked to pay $2,128.57 for a SNF stay. A SNF stay falls within the SNF 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 a SNF stay provided from December 1, 2020, to January 7, 2021.