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

We decided that the Plan does not have to pay for transportation services (A0425 and A0428) provided on September 26, 2019.You asked the Plan to pay for the transportation services. You say that you would like reconsideration because the transportation was medically necessary.The Plan denied your request. The Plan says the clinical notes indicate transportation other than an ambulance could have been utilized without endangering the individual's health.Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 the transportation services. Our reviewer says that based on the documentation provided the records do not support that other means of transport were contraindicated. The records do not support that the member needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. Our physician reviewer found the records do not support that the ambulance transport was medically reasonable and necessary for the member. Provided records indicate the member was ambulatory with a walker and able to transfer from supine to sitting during the time period of the ambulance transport.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 transportation services have not been met.Therefore, we decided that the Plan does not have to pay for transportation services (A0425 and A0428) provided on September 26,2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe accession of tissue, gross and microscopic examination, preparation and transmission of written report (D0473) provided on April 25, 2019.You asked the Plan to pay forthe accession of tissue, gross and microscopic examination, preparation and transmission of written report. You say that you have no control over what the providers do. You also say that you tell all of your medical providers that all tests and referralshave to be within the Plan's system.The Plan denied your request. The Plan says this service is 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 pay forthe accession of tissue, gross and microscopic examination, preparation and transmission of written report (D0473) provided on April 25, 2019.
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 the enrollee currently meets IRF admission criteria
according to Medicare guidelines. The Plan denied your request. The Plan says the denial of authorization for
IRF service is correct.
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. While the
enrollee may benefit from continuing physical therapy and occupational therapy, there is no evidence of need
for an intensive therapy program with therapy 3 hours per day and frequency physician oversight. 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. The enrollee's rehabilitation needs can be met in a lower
intensity setting such as skilled nursing facility once the enrollee is medically stable.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 13, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says non-emergent services by non-participating 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 provider at issue in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 on February 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on February 14, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says out-of-network services are not covered.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 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 forthe medical services provided to you by an out-of-network provideder on February 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 9, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 drug testing services provided on July 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 30, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed
service cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for
coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to
pay for the drug testing services provided on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee.You asked the Plan to pre-approve the device. You say that this is medically necessary.The Plan denied your request. The Plan says this service is considered experimental and investigational, as its use has not been established as very effective for heart failure management in the literature.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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.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 device have not been met.Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on March 10, 2020 and March
16, 2020.
You asked the Plan to pay for the dental services. You say that you were informed by the dental office that they
accept your insurance. You say that you were misled. The Plan denied your request. The Plan says payment
cannot be issued for services performed by an opt out provider.
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, services received from a provider who
has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan
does not have to pay for the dental services provided on March 10, 2020 and March 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on December 19, 2019 by an out of network (OON) provider.You askedthe Plan to pay forthe OON services. You say that the service is an extension of the initial visit.The Plan denied your request. The Plan says there is no network deficiency for the services.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 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 forthe lab services provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung
Cancer Screening (G0297).
You asked the Plan to pre-approve the LDCT Lung Cancer Screening. You say that the screening is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that for the procedure to be covered, the enrollee
must be age 55 - 77 years.
We looked at the file and Medicare rules. The record shows the enrollee is over the age of 77. Based on this
information, we decided that Medicare rules for coverage of the LDCT Lung Cancer Screening have not been
met. Therefore, we decided that the Plan does not have to pre-approve a Low Dose Computed Tomography
(LDCT) Lung Cancer Screening (G0297).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe ambulance transport provided on February 15, 2020.You asked the Plan to waive the deductible forthe ambulance transport. The Plan denied your request. The Plan says that the claim processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible for covered medical services. The item or service you asked the Plan to waive the deductible for falls within the benefit category of covered medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time the ambulance transport was received on February 15, 2020.Therefore, we decided that the Plan does not have to waive the deductible forthe ambulance transport provided on February 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on January 13, 2020 to February 14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office services. You say that you were told that prior authorization was not obtained. The Plan denied your request. The Plan says prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services. 
 
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 office services provided on January 13, 2020 to February 14, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reconstruction of the jaw for endosteal implants.
You asked the Plan to pre-approve the reconstruction of the jaw for endosteal implants. You say that the
process of having extractions is medically necessary. You also say that not having the requested dental
procedures is putting your health at risk. The Plan denied your request. The Plan says this this request is due to
teeth decay and periodontal disease. The Plan also says that this service is not covered if performed primarily
for dental related conditions.
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, this service cannot be covered by
Medicare since it is a service for the replacement of teeth, meaning that it falls into the category of excluded
dental services. Further, the Plan offers an extra benefit which also does not cover implants. Therefore, we
decided that the Plan does not have to pre-approve a reconstruction of the jaw for endosteal implants.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Norco 10-325mg Tablets.
You asked the Plan to pre-approve Norco. You say that this drug is medically necessary for pain treatment. The
Plan denied your request. The Plan says this type of self-administered drug 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 selfadministered
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 Norco 10-325mg Tablets.
Benefits for Norco 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant surgeon services rendered on November 27, 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 the provider type is not covered.The Plan must follow Medicare rules. The rules say that assistant surgeon services must be billed with the AS modifier.We looked at the file and Medicare rules. The file shows that the services were not billed with the required AS modifier. 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 assistant surgeon services rendered on November 27, 2019
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan of the
abdomen and pelvis (74176) provided March 2, 2020.
You asked the Plan to waive the copayment for the CT scan. 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 $275
copayment for Advanced Imaging.
You have been asked to pay a $275 copayment for the CT scan. the CT scan falls within the Advanced Imaging
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 Computed Tomography (CT)
scan of the abdomen and pelvis (74176) provided March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system, includes all accessories and supplies, to be provided by an out of network provider. 
 
You asked the Plan to pre-approve a high frequency chest wall oscillation system, includes all accessories and supplies (E0483) from an out of network provider. You say that the enrollee wants to use the out of network supplier. The Plan denied your request. The Plan says the services are available in network. 
 
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system, includes all accessories and supplies, to be provided by an out of network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe Part B injection and its administration provided on February 11, 2020.You asked the Plan to waive the cost share forthe Part B injection and its administration. You say that you were not informed there would be a cost share in the amount of $304.60. You say you cannot afford this copayment.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each Medicare-covered Part B drug and a $390 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other physician or surgical chargesYou have been asked to pay a total of $304.60 for the Part B injection andits administration. The Part B injection falls within the "Medicare Part B Prescription Drugs" benefit category. The administration falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the cost share forthePart B injection and its administration provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hepatitis A and Hepatitis B injections received on March 9, 2020.
You asked the Plan to pay for the Hepatitis A and Hepatitis B injections. You say that this vaccine is needed for protection after a autologous transplant. The Plan denied your request. The Plan says the services received are not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Hepatitis A and Hepatitis B injections. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Hepatitis A and Hepatitis B injections. Therefore, we decided that the Plan does not have to pay for the Hepatitis A and Hepatitis B injections received on March 9, 2020.