Persius/hicric huggingface dataset:
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 previous claims for services from the provider have been paid by the Plan and you asked the Plan to reconsider their denial. 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 March 26, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary to have decreased pain and improved quality of life. The Plan denied your request. The Plan says the requested injection is supported when there is advanced imaging showing the structure of the sacroiliac joint system is inflamed or swollen.
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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found an MRI report dated 12/12/2019 of the lumbar spine with and without contrast was provided. This showed multilevel degenerative disc and facet disease with multilevel central canal stenosis and mild foraminal stenosis. No imaging studies of the sacroiliac joint indicative of spondyloarthropathy were provided. In the absence of imaging studies confirming the diagnosis coverage for the requested procedure is not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethermal radiofrequency injection services.You asked the Plan to pre-approvethe thermal radiofrequency injection services. You say that you are unable to walk or stand without being in severe pain. You say that you have been in bed taking medication and with a TENS unit. You say that this is a painful procedure and that you would not be asking to get it done if it wasn't necessary. You say that the ablations don't last as long as the guideline of 2 per rolling 12 months.The Plan denied your request. The Plan says the criteria for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that no more than two thermal radiofrequency sessions will be reimbursed in any rolling 12 month year.We looked at the file and Medicare rules. The records show that you received lumbar thermal radiofrequency injections on September 27 and December 27, 2019. This means that two thermal radiofrequency sessions were reimbursed in a rolling 12-month year, and that the benefit for this type of service is currently exhausted. Based on this information, we decided that Medicare rules for coverage of the thermal radiofrequency injection services have not been met. Therefore, we decided that the Plan does not have to pre-approvethermal radiofrequency injection services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on March 3, 2020.
You asked the Plan to waive the copayment for an ambulance trip. You say that you feel like the Plan should pay for these copayments. The Plan denied your request. The Plan says the correct copayment has been 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 $350 copayment for ambulance services. You have been asked to pay a $350 copayment for an ambulance trip. An ambulance trip falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the diabetic slippers.
You asked the Plan to reimburse you for the diabetic slippers. You say that the Plan should reimburse you. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Diabetic slippers are not a covered benefit. Therefore, we decided that the Plan does not have to reimburse you for the diabetic slippers.
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 , given the severity of the surgery and adjustments needed to be made for everyday living, IRF care is imperative. You say that all doctors and physical therapists have been recommending IRF care for the past 2 weeks. The Plan denied your request. The Plan says the documentation provided does not support the need for IRF care.
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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 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 enrollee requires an interdisciplinary therapy care
due to his serious, life threatening constellation of acute medical problems that have left him at a functional
status below his baseline. The Plan denied your request. The Plan says the requirements for coverage 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 he complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not
support that his functional level requires this on an 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for cone beam CT, teeth 1 and 32 (D0380) pulp vitality tests, tooth 3 (D0460) and endodontic therapy, tooth 3 (D3330)provided January 8, 2020.You asked the Plan to pay forthe dental services. You say that you are appealing because you could not find a network provider in your area. You were going through a lot of pain and had to have the surgery done immediately because of an infection.The Plan denied your request. The Plan says these services are not covered under the plan benefits.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 forcone beam CT, teeth 1 and 32 (D0380) pulp vitality tests, tooth 3 (D0460) and endodontic therapy, tooth 3 (D3330) provided January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided January 20, 2020 to January 31, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that the provider was an in-network provider and the fillings and crown should be covered. The Plan denied your request. The Plan says dental services must be rendered by an in-network 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. The health plan contract on page 92 specifically says services must be rendered by a contracted provider. 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 the dental services provided January 20, 2020 to January 31, 2020 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe compression stockings identified with code A6533 that were issued on January 28, 2020.You asked the Plan to pay forthe compression stockings. You say that your doctor recommended you the stockings to treat abnormal bruising.The Plan denied your request. The Plan says your request is not a covered benefit because Medicare does not cover compression stockings.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pay forthe compression stockings identified with code A6533 that were issued on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings to aid in swelling after your knee replacement. The Plan denied your request. The Plan says you do not have a qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on December 17, 2019.You asked the Plan to pay forthe 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 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 services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (A9150, 98940) provided to you on March 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered.
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. 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 services Our reviewer says that the requested chiropractic services (CPT 98940) do not meet Medicare coverage criteria. Our physician reviewer found that there are no submitted imaging studies to reveal evidence of a subluxation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 98940 have not been met. Additionally, the non-prescription drugs (A9150) are not covered when provided by a chiropractor. Therefore, we decided that the Plan does not have to pay for the chiropractic services (A9150, 98940) provided to you on March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for cone beam computed tomography (D0382) provided March 12, 2020.
You asked the Plan to pay for the special x-rays. You say that the provider told you that you needed to have the CT scan and that it was necessary for proper treatment and extraction. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
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 cone beam computed tomography (D0382) provided March 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on January 27, 2020.
You asked the Plan to waive the copayment for the ambulance ride. You say that you do not believe you should pay this high copayment for the ambulance trip. You say this would be covered in full by the Plan. 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 a $350 copayment for Medicare-covered ambulance services per trip. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $350 copayment for the ambulance ride.
You have been asked to pay a $277.66 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance ride provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power elevation system.
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 item is not covered.
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. We looked at the file and Medicare rules. The item at issue is a power seat elevation feature. This item is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power elevation system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe arthrocentesis provided on January 21, 2020.You asked the Plan to waive the copayment forthe arthrocentesis. You say that you were never in the hospital when you received this service. You say you were an outpatient and should be billed this way. 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 a $325 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $325 copayment for the arthrocentesis.You have been asked to pay a $243.22 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows you were billed for your outpatient service by an outpatient hospital.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 forarthrocentesis provided on January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete series x-rays (D0210) provided February 27, 2020.You asked the Plan to pay for the dental services. You say that when you called and spoke to a plan representative, he told you that the practice was in network and you were covered. The representative did not say a certain kind of x-ray so you assumed it was covered.The Plan denied your request. The Plan says this service is not covered under the plan benefits.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 complete series x-rays (D0210) provided February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on December 31, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care 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 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 nurse practitioner services provided on December 31, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services (99199, S9122) provided from July 1, 2019 to August 25, 2019 by a provider that is not enrolled in the Medicare program.You asked the Plan to pay forhome health services. Yousay that Medicare providers did not provide adequate care.The Plan denied your request. The Plan says payment cannot be made for services received from a provider that is not enrolled in the Medicare program.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.We looked at the file and Medicare rules. The services at issue were provided by a provider that is not enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of home health services have not been met.Therefore, we decided that the Plan does not have to pay forhome health services (99199, S9122) provided from July 1, 2019 to August 25, 2019 by a provider that is not enrolled in the Medicare program.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Belbuca.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Belbuca.