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

We decided that the Plan does not have to waive the copay forthe ambulance transport provided on January 24, 2020.You asked the Plan to waive the copay forthe ambulance transport. You say that you should not be responsible because your doctor advised that you needed the ambulance transport.The Plan denied your request. The Plan says that cost sharing applied for each one-way trip.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 $250 copay for Medicare-covered ambulance services. You have been asked to pay a $247.44 copay for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance services benefit category. This means that you have been asked to pay less than 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 copay forthe ambulance transport provided on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle and accessories.
You asked the Plan to pre-approve a Group 2 power operated vehicle (K0806)and accessories. You say that you need a scooter for occasional use in your home, for shopping, errands, and to fit in in your car. The Plan denied your request. The Plan says Group 2 power operated vehicles are not covered by Medicare.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the POV is being requested for outside the home. Neither Medicare nor the Plan cover POVs for use only outside the home. Also, Medicare does not cover Group 2 POVs (K0806). This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power operated vehicle and accessories.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that the services were provided at your home. You say that the Plan should reconsider their denial of the ambulance services.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 June 10, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services rendered on December 13, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the appropriate POS code. We looked at the file and Medicare rules. The provider submitted a claim for procedure code 88300 with POS code 22 for outpatient hospital; however, the file shows that the enrollee was not under outpatient hospital status for the date of service at issue. 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 surgical pathology services rendered on December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network primary care physician (PCP).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
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 referral to an out-of-network primary care physician (PCP).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings, extraction, periodic oral evaluation, and prophylaxis provided on January 9, 2020 by an OON provider.You asked the Plan to pay for the bitewings, extraction, periodic oral evaluation, and prophylaxis. You say that the Plan has no record of you having the enhanced dental and vision plan. You also say that you are certain you requested to be signed up for the enhanced plan.The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that no benefits are available for procedures performed by OON providers.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 covered when they are received OON. The records show that you did not elect to purchase an optional supplemental package when you first enrolled with the Plan. The Plan confirmed that you elected to enroll in the optional supplemental package on January 10, 2020, which took effect February 1, 2020.Therefore, we decided that the Plan does not have to pay for the bitewings, extraction, periodic oral evaluation, and prophylaxis provided on January 9, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services rendered by an assistant at surgery (25609) provided on October 25, 2019.You asked the Plan to pay for the assistant at surgery services. You say that you would like reconsideration because this provider was requested to assist by the rendering surgeon.The Plan denied your request. The Plan says the documentation does not support the service billed.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Additionally, the documentation submitted does not indicate that an assistant at surgery was present.Therefore, we decided that the Plan does not have to pay for services rendered by an assistant at surgery (25609) provided on October 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 27, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on March 2, 2020 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that your Plan does not state that the provider has to be in-network. You also say that the entire allowance should be utilized for preventive services. The Plan denied your request. The Plan says you received services from an OON provider. The Plan also says that if the provider is OON with the Plan, the provider can bill the enrollee the difference.
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 OON dentist can bill you for additional costs if what they charge is more than the maximum benefit amount for preventive services covered by the Plan. The record shows that this claim was processed correctly with a $113 allowance. Your OON dentist can bill you for the difference. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on March 2, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 7, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrolleemust receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 servicesat 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 physician's services providedon November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you have to wear diapers daily because of your health issues. You say that you take medication to help you have bowel movements and most of the time it happens without you being able to make it to a bathroom. You stated that you have an allowance per month which only pays for one package of supplies and you need more. You say that the requested supplies are very necessary for you. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on November 26, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a facility place of service. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveenteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (CPT Code B4154). You asked the Plan to pre-approveeternal formula. You say that you have been taking this shake for four (4) years and never been denied.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eternal formula have not been met. You are able to take food by mouth, and do not have a feeding tube. Per Medicare rules, ENTERAL nutrition products that are administered orally (taken by mouth) and related supplies are non-covered.Therefore, we decided that the Plan does not have to pre-approveenteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (CPT Code B4154).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0822) and wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each (E1226), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The information sent in does not show when the enrollee's current wheelchair was bought and what kind it is. It does not show what happened to it, how it does not work and why it cannot be fixed. It does not show the required paperwork (a Michigan Certificate of Medical Necessity). It does not show that the enrollee has pressure sores or use a catheter daily to urinate. The requested back incline is not medically necessary. The enrollee would have to meet all the rules before this could be approved. Therefore, we decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0822) and wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each (E1226), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for inpatient hospital care, for the enrollee.
You asked the Plan to provide coverage for inpatient hospital care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 provide coverage for inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the documentation pre-operatively did not meet the threshold for an intensity of services or underlying member hemodynamic instability that could only be managed in an acute inpatient setting. The review has determined that the record does not show that the admitting physician reasonably expects that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. 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 hospital care have not been met. Therefore, we decided that the Plan does not have to provide coverage for inpatient hospital care, for the enrollee.
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 based on the enrollee's current condition and functional deficits, as well as his multiple comorbidities, his attending physicians have determined that he meets the IRF criteria for coverage. The Plan denied your request. The Plan says the records do not indicate that the criteria for coverage of IRF care have been met. The Plan says that the records do not show that the enrollee has a need for intensive rehabilitation and a multidisciplinary team for care. The Plan say that the enrollee can safely receive the services needed in other settings.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin and O2 care, and daily therapy can be provided at a SNF. The enrollee is mostly minimal assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy will allow for measurable gains to be attained in a reasonable period. 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: 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 services are medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. Functionally, given he is at minimal assist level, IRF level of therapies are not necessary. The enrollee may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accessory, attendant control, proportional, including all related electronics and fixed mounting hardware (E2331), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The 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. The member can use a joystick at home. The attendant controls is for use of power wheelchair in the community. Both attendant control and member control is not operated. The evaluator stated that member is able to safety operate wheelchair at home with a joystick. Therefore the attendant control is not covered. Therefore, we decided that the Plan does not have to pre-approve power wheelchair accessory, attendant control, proportional, including all related electronics and fixed mounting hardware (E2331), for the enrollee.