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

We decided that the Plan does not have to pay for the ambulance services provided on November 6, 2020.
You asked the Plan to pay for the ambulance services. You say that the facility called for this service and it was
an emergency. 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 November 6, 2020. 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 provided on November 6,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the fitness equipment purchased August 31, 2020.
You asked the Plan to pay for the fitness equipment. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the items were purchased before the extended timeframe for additional reimbursement.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits up to a $300 Wellness Allowance in a calendar year. The Plan extended use of the Wellness Allowance benefit to include exercise equipment purchased between October 1 and December 31, 2020. The Plan's rules for coverage of gym benefits have not been met because the equipment was purchased prior to October 1, 2020. Therefore, we decided that the Plan does not have to pay for the fitness equipment purchased August 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cologuard screening testing.

You asked the Plan to pre-approve Cologuard test. You say that you need this testing due to your underlying conditions. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because you are not between 50 and 85 years old.

The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered once every three years for Medicare beneficiaries that are between age 50 to 85, asymptomatic, and at average risk of developing colorectal cancer. 

We looked at the file and Medicare rules. You are not within the covered age range of 50 to 85 years. Based on this information, we decided that Medicare rules for coverage of Cologuard test have not been met. Therefore, we decided that the Plan does not have to pre-approve Cologuard screening testing.
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 you would like reconsideration because the LTACH admission is medically necessary. The Plan denied your request. The Plan says the member is in the acute care hospital that can provide ongoing acute care services.

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 the enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) supplies provided on September 1, 2020, by an out of network (OON) provider.

You asked the Plan to pay for CPAP supplies. You say that this equipment was necessary. The Plan denied your request. The Plan says prior authorization was not obtained for the services received.

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 continuous positive airway pressure (CPAP) supplies provided on September 1, 2020, by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on September 28, 2020.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says prior
authorization was not obtained as required under the Plan benefits. Services rendered by non-participating
providers require prior authorization as outlined in the enrollees Evidence of Coverage.

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
physical therapy 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 physical therapy services provided on
September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided December 19, 2020.

You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that you would like this claim reprocessed and approved for payment based on medical necessity. The Plan denied your request. The Plan says this claim denied correctly and no reimbursement is due.

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. Specifically, the medical records do not indicate that the provider discussed the need for the requested device with the enrollee. 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 therapeutic continuous glucose monitor provided December 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for duplex scan of extracranial arteries (93380) provided October 30, 2020.

You asked the Plan to pay for the duplex scan. You say that the attached medical reports are being submitted to support the services rendered as medical necessity. Please process claim for reconsideration per contract guidelines. The Plan denied your request. The Plan says this is a duplicate of a claim that was previously approved and paid.

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 93880 is duplex scan of extracranial arteries, complete bilateral study.

We find that CPT code 93880 is not supported in the medical record. Specifically, the submitted documentation supports 1 unit of 93880 which was previously approved and paid by the plan. Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for duplex scan of extracranial arteries (93380) provided October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing home visit provided on August 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that it is the responsibility of the nursing home to verify insurance and obtain approval. The Plan denied your request. The Plan says authorization for out-of-network services was not obtained.
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 in this case is not a network provider with the Plan. The Plan had network providers available to 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 nursing home visit provided on August 7, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on September 19, 2020.
You asked the Plan to pay for the emergency department visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says Original Medicare is responsible for this claim.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the emergency department visit provided on September 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ability drive joystick, ability drive interface,
mounting hardware, eye tracking system with Tobii technology, self-leveling cup holder, and attendant
proportional control.
You asked the Plan to pre-approve an ability drive joystick, ability drive interface, mounting hardware, eye
tracking system with Tobii technology, self-leveling cup holder, and attendant proportional control. You say
that the requested items are medically reasonable. The Plan denied your request. The Plan says these items
cannot be approved.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. The rules also say that items and services that are not medically necessary are not covered.
The rules also say that an attendant control cannot be covered when a power wheelchair with a controller that is
operated by the member is covered.
Cup Holder
The cup holder 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.
Electronic Interface
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 ability drive joystick, ability drive
interface, mounting hardware, and eye tracking system with Tobii technology. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the provided records did not provide documentation that the requested gaze-control device is
approved by the Food and Drug Administration as safe and effective.
Attendant control
The attendant control is statutorily non-covered when a power wheelchair with a controller that is operated by
the member is covered.
Therefore, we decided that the Plan does not have to pre-approve an ability drive joystick, ability drive
interface, mounting hardware, eye tracking system with Tobii technology, self-leveling cup holder, and
attendant proportional control.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on May 28, 2020.

You asked the Plan to pay for the laboratory services. You say that the medically necessary services were provided in good faith. The Plan denied your request. The Plan says in-network providers were available to perform 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 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 laboratory services provided by an out-of-network provider on May 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and accessories (E0673 and E0675) provided on December 10, 2020.

You asked the Plan to pay for the pneumatic compression device and accessories. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested equipment is not covered for the member's condition.

The Plan must follow Medicare rules. Medicare rules say that if the base PCD is not covered, related accessories are not eligible for reimbursement. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and accessories have not been met. Specifically, the record does not indicate that a covered PDC was was supplies; therefore, the requested accessory is not eligible for reimbursement. Additionally, CPT code E0675 is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and accessories (E0673 and E0675) provided on December 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CT Scan of the head (70450).

You asked the Plan to pre-approve the CT Scan of the head. You say that you would like reconsideration because the requested CT Scan is medically necessary. The Plan denied your request. The Plan says there is no documented physical exam, specific rationale given for the study, and no symptoms such as headache, acute neurological deficit, seizures, history of trauma, history of cancer, evidence of infection, or syncope.

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 the CT Scan of the head. Our reviewer says that the requested CT Scan is not medically reasonable and necessary. Our physician reviewer found there is no clinical indication for the requested CT Scan of the head. 

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 CT Scan of the head have not been met. Therefore, we decided that the Plan does not have to pre-approve the CT Scan of the head (70450).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of an endosteal implant (D6010), sinus augmentation (D7952) and deep sedation/general anesthesia (D9222, D9223) provided on December 15, 2020.

You asked the Plan to pay for the dental services. You say that you did not realize you could not see any dentist. You only knew that you had a $2,000 allowance for dental services. The Plan denied your request. The Plan says the provider in question has opted out of Original Medicare. Dental services received from opt-out providers cannot be covered.

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 cannot be covered under this benefit when they are received from a provider who has chosen to opt-out of Original Medicare. The provider in question was opted-out at the time of these services. Therefore, we decided that the Plan does not have to pay for the surgical placement of an endosteal implant (D6010), sinus augmentation (D7952) and deep sedation/general anesthesia (D9222, D9223) provided on December 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the ultrasound provided on December 18, 2020.

You asked the Plan to waive the co-payment for the ultrasound. You say that you had an ultrasound done with your mammogram for years as a screening and did not pay a co-payment. You say that the claim should be reprocessed. The Plan denied your request. The Plan says the co-payment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 co-payment for diagnostic procedures and tests at all in-network locations of service.

You have been asked to pay a $50 co-payment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The ultrasound is considered a diagnostic service. 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 co-payment for the ultrasound provided on December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on January 7, 2021.

You asked the Plan to pay for a bone replacement graft. You say that you are not sure why the provider used this code for the service. The Plan denied your request. The Plan says the service at issue 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 for a bone replacement graft (D7953) provided on January 7, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute and does not require transfer to LTACH.
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. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. You are receiving acute hospital care, and acute care services have not been denied. The documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post stabilization inpatient care provided February 27, 2019 to March 1, 2019.
You asked the Plan to pay for the post stabilization care. You say that the plan was made aware of the enrollee's condition every day and the plan failed to effectuate the prompt transfer and the enrollee was too sick to be discharged safely for that duration. The Plan denied your request. The Plan says the enrollee's condition had stabilized, and the hospital did not request authorization prior to providing post stabilization care.
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 the post stabilization care. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, the enrollee was stable for transfer upon completing her evaluation at the ED. Her CT head was normal and her mental status was normal. There was no notation in the medical records for the need to continue her care in the hospital where she was and her records indicate that she was 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 the post stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for post stabilization inpatient care provided February 27, 2019 to March 1, 2019.