Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to not adjust the claimforthe duplex scan provided on August 20, 2019.You asked the Plan to not pay forthe duplex scan. You say that the Department of Veterans Affairs should pay this claim.The Plan denied your request. The Plan says they areyour primary payer.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has certain types of other insurance. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has paid the claim as primary payer.Therefore, we decided that the claim processed correctly for the duplex scan provided on August 20, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second skin protection seat cushion (E2623), power
seat elevation system (E2300), and attendant control (E2331).
You asked the Plan to pre-approve a second skin protection seat cushion, power seat elelevation ystem, and
attendant control. You say that the enrollee needs these items to function. The Plan denied your request. The
Plan says these items are not covered in this case.
The Plan must follow Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in
addition to a beneficiary-operated drive control system, it will be denied as non-covered. A power seat
elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily
medical in nature. Medicare considers equipment to be reasonable and necessary if the equipment does not
serve the same purpose as other equipment already available to an enrollee.
We looked at the file and Medicare rules. The requested power seat elevation system is non-covered. The
attendant control is being requested in addition to a beneficiary-operated drive control system. The requested
skin protection seat cushion is duplicative to the skin protection seat cushion approved under code E2622.
Based on this information, we decided that Medicare rules for coverage of a second skin protection seat
cushion, power seat elevation system, and attendant control have not been met. Therefore, we decided that the Plan does not have to pre-approve a second skin protection seat cushion (E2623), power seat elevation system
(E2300), and attendant control (E2331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora comprehensive oral evaluation (D0150) provided September 2, 2020.You asked the Plan to pay forthe oral exam. You say that the service was medically necessary.The Plan denied your request. The Plan says the benefit for this service was exhausted.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, coverage for comprehensive oral evaluations islimited to once every 3 plan years. This service was already provided on February 24, 2020.Therefore, we decided that the Plan does not have to pay fora comprehensive oral evaluation (D0150) provided September 2, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea magnetic resonance angiography (MRA) of the head (70544).You asked the Plan to pre-approvean MRA of the head. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that specific criteria must be met for Medicare to provide coverage for MRA of the head and neck.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 an MRA of the head. Our reviewer says that the services are medically necessary. Our physician reviewer found the plan's stated position is that an MRI of the brain was approved on January 8, 2021 and results of that test need to be viewed first.  However, review of the records shows the plan deniedthe request for an MRI of the brain on January 8, 2021. The fact is the MRI of the brain and the requested MRA studies are indicated and should be approved in a enrollee with pulsatile tinnitus which is worsening.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRA of the head have been met.Therefore, we decided that the Plan has to pre-approvea magnetic resonance angiography (MRA) of the head (70544).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 pay for the preventive procedure, first intraoral periapical x-ray, and crown provided on September 4, 2020 by an OON provider.
You asked the Plan to pay for the preventive procedure, first intraoral periapical x-ray, and crown. You say that the Plan said that they would pay 50% of the crown. You also say that after receiving the service you were advised by the Plan that they would only pay 50% of the contracted amount, and said you needed to meet the $100 deductible. The Plan denied your request. The Plan says your claim was paid correctly.
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 responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the preventive procedure, first intraoral periapical x-ray, and crown provided on September 4, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you believe the enrollee's medical management and rehab needs require an inpatient rehab stay and close physician supervision.The Plan denied your request. The Plan says the criteria for admission to the Acute Inpatient Rehabilitation setting have not been met.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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Our physician reviewer also found that 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.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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0676) provided to the enrollee on August 27, 2020.You asked the Plan to pay fora pneumatic compression device. You say that the device was medically necessary for the enrollee.The Plan denied your request. The Plan says that the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0676) provided to the enrollee on August 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee has been seen by two doctors and she has declined in mobility. You say that the enrollee has had two falls in the past and has limited movement. You say that the enrollee has been evaluated in the home and it was determined that she needs inpatient rehab.The Plan denied your request. The Plan says the criteria for coverage of IRF care have not been met.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 topre-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 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 is living at home with decline in functional mobility and weakness. The enrollee's medical conditions are stable. There are no medicalneeds requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim caries arresting medicament application (D1354)
and the filling (D2393) provided on September 17, 2020.
You asked the Plan to pay for the medicament application and filling. You say that the services should be
covered. The Plan denied your request. The Plan says there is a $1,000 annual maximum benefit for covered
dental services. The Plan says that the benefit has been exhausted. The Plan also says that after the annual
maximum is exhausted, any remaining charges are your responsibility.
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, there is a $1,000 annual maximum
benefit for covered dental services.
Date of Service Total Claimed Total Allowed Total Paid Your Responsibility
7/21/2020 $154 $115 $115 $0
8/20/2020 $1,516 $950 $885 $315.80
9/15/2020 $406 $406 $0 $406
TOTAL: $1,000 $721.80
The Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges
are your responsibility. Therefore, we decided that the Plan does not have to pay for the interim caries arresting
medicament application (D1354) and the filling (D2393) provided on September 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient post stabilization care provide on March 3, 2020, through March 6, 2020.You asked the Plan to pay forinpatient post stabilization care. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized by 7:00 pm on March 3, 2020 and subsequent care was post stabilization care, not approved in compliance with the health plan's authorization procedures. The Plan has paid for all emergent care up to the point of stability.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient post stabilization care. Our reviewer says that the service is not medically necessary. Our physician reviewer found all the inpatient care provided at the non-participating facility after 7:00 pm on March 3, 2020, through March 6, 2020 was not medically necessary or reasonable. The treating physician did not document (in the physician notes,on a form, or in an order) that the patient was not stable for transfer on any dates of service.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient post stabilization care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient post stabilization care provide on March 3, 2020, through March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic services (G0283, 99213) provided September 16, 2020 to September 23, 2020.You asked the Plan to pay forthe chiropractic services. You say that the services were medically necessary.The Plan denied your request. The Plan says the chiropractic services at issue are not a covered benefit.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forchiropractic services (G0283, 99213) provided September 16, 2020 to September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on September 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on September 16, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe train of four testing (CPT 95999) provided on May 28, 2020.You asked the Plan to pay forthe testing. The Plan denied your request. The Plan says this is a bundled service.The Plan must follow Medicare rules. Medicare rules say that all services which are integral to accomplishing a procedure are considered a component part of a comprehensive code.IONM services cannot be performed without TOF monitoring. This means that TOF testing is considered integral to the performance of IONM services. As such, this component of the procedure is included in payment for the overall IONM monitoring service which was already paid. No separate payment can be made for this part of the service.Therefore, we decided that the Plan does not have to pay forthe train offour testing (CPT 95999) provided on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on February 26, 2020, and
July 22, 2020.
You asked the Plan to pay for the acupuncture services. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says the record does not show the provider was under the appropriate level of
supervision of a physician, physician assistant or nurse practitioner.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to twelve sessions per ninety-day period, and no more
than twenty sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, the record does not show the auxiliary personnel was
under the appropriate level of supervision. Therefore, we decided that the Plan does not have to pay for
acupuncture services provided on February 26, 2020, and July 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forroutine disposable supplies (A0398) provided on June 14, 2020You asked the Plan to pay forroutine disposable supplies. You say that the service was medically necessary.The Plan denied your request. The Plan says the service is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that items and services which include but are not limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are no longer paid separately for ambulance services.  Payment is based solely on the ambulance fee schedule.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of routine disposablesupplies have not been met.Specifically, routine disposable supplies are not a covered service.Therefore, we decided that the Plan does not have to pay forroutine disposable supplies (A0398) provided on June 14, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1830) provided on October 15, 2019, by
an out-of-network (OON) provider.
You asked the Plan to pay for the orthosis. You say that based on the current diagnosis the physician ordered
this DME/Orthotic for home use to stabilize and protect from further injury and reduce pain. Please see
attached documents supporting medical necessity ad order. 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 the knee orthosis (L1830) provided on October 15,
2019, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on October 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedermatology services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveOON services. You say that the in-network provider does not offer superficial radiation.The Plan denied your request. The Plan says providers in-network are able to treat your condition.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the dermatology services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services.Therefore, we decided that the Plan does not have to pre-approvedermatology services to be provided by an out of network (OON) provider.