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 May 24, 2020.

You asked the Plan to pay for the ambulance services. You say that you find this unfair for the enrollee not to be covered for paramedic treatment at home. 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 May 24, 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 by Rural Metro Ambulance on May 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99345) provided on February 28, 2020 by an out of network (OON) provider. You asked the Plan to pay for an OON home visit. You say that this service was provided in good faith. The Plan denied your request. The Plan says this service was not authorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 the home visit (99345) provided on February 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for selective catheter placement (36248x2) provided on February 3, 2020.

You asked the Plan to pay for the selective catheter placement. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

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 36248x2 is selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate) .

We asked our coder 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 selective catheter placement. Our reviewer says that CPT code 36248 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that a selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate) (x2 RT ) was performed on the billed date of service.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the selective catheter placement have not been met. Therefore, we decided that the Plan does not have to pay for selective catheter placement (36248x2) provided on February 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VertiFlex Superion Interspinous Spacer. 
 
You asked the Plan to pre-approve the VertiFlex Superion Interspinous Spacer. You say that you would like 
reconsideration because this device is medically necessary. The Plan denied your request. The Plan says the 
spacer is contraindicated for people with a Body Mass Index greater than 40. 
 
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 VertiFlex Superion Interspinous 
Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the spacer is experimental in spinal surgery and more 
research is needed to show safety and efficacy of the spacer in the spine. 
 
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 VertiFlex Superion Interspinous Spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a VertiFlex Superion Interspinous Spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health services provided on January 7, 2020 
through January 27, 2020. 
 
You asked the Plan to pay for the inpatient mental health services. You say that you would like reconsideration 
because these services were medically necessary. The Plan denied your request. The Plan says the member was 
no longer a threat to himself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health services.  
Our reviewer says that it did not appear medically necessary and reasonable to have psychiatric care provided 
at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the member 
did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. Our physician reviewer 
found it did not appear that active treatment was taking place beyond the date in question. It did not appear that 
the services for the dates in question were reasonably expected or medically necessary to improve the 
member?s condition or for the purpose of diagnosis. 
 
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 inpatient mental health services have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient mental health services provided on January 7, 2020 through 
January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the crown provided on February 13, 2020. 
 
You asked the Plan to pay for the crown. You say that you needed a new crown to save what remained of the 
tooth. You say that you did not find where it indicates pre-authorization is required. The Plan denied your 
request. The Plan says that the dental office should have submitted a pre-authorization for the crown. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The crown was provided by a contract provider. The contract says that crowns are covered up to two every 
calendar year. The dental contract does not clearly indicate that prior authorization is required for all services. 
There is no evidence that the network provider gave notice that the crown provided would not be covered. 
Under Medicare rules, this means the crown is considered approved by the Plan. Therefore, we decided that the 
Plan has to pay for the crown provided on February 13, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport from a facility to your home on April 3, 
2020. 
 
You asked the Plan to pay for this transport. You say that this transport was medically necessary due to Covid 
19. The Plan denied your request. The Plan says you were treated for a urinary tract infection, not Covid 19 and 
you did not have prior authorization for non-emergent ambulance transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules. The records provided do not show it was medically necessary for you to be transported 
home by ambulance. The Plan did not authorize this transport as is required by your contract. Medicare rules 
for coverage of this transport. have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance transport from a facility to your home on April 3, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided January 29, 2020 to February 
2, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that the enrollee's needs could have been met in an observation 
setting. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier emergency 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided January 29, 2020 to February 2, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on March 17, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
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 claim is missing the main code 
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of 
this claim have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
provided to the enrollee on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on December 6, 
2019.  
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says you did not have prior authorization for out of network physician care. 
 
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 out of network physician services provided on 
December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CPAP provided from January 31, 2019 
to December 19, 2019. 
 
You asked the Plan to waive the coinsurance for the CPAP . You say that you dispute these charges. The Plan 
denied your request. The Plan says that this was processed and paid correctly. 
 
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 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for the CPAP. The CPAP falls within the durable medical 
equipment (DME) and related supplies 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 coinsurance 
for the CPAP provided from January 31, 2019 to December 19, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for personal caregiver services received from August 16, 2019 to 
December 22, 2019. 
 
You asked the Plan to pay for the services. You say that you were told by a plan representative that you have a 
benefit for home health. The Plan denied your request. The Plan says there is no benefit for this type of service. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in 
this appeal. Therefore, we decided that the Plan does not have to pay for personal caregiver services received 
from August 16, 2019 to December 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care rendered on March 22, 2020 to April 
4, 2020. 
 
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 services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 
We looked at the file and Medicare rules. The file shows that the billed evaluation and management services 
were previously paid by the Plan for a provider within the same group practice. The services at issue are 
bundled into that previous payment. Therefore, we decided that the Plan does not have to pay for the nursing 
facility care rendered on March 22, 2020 to April 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an automated external defibrillator (K0606) provided March 
14, 2020. 
 
You asked the Plan to pay for the defibrillator. You say that the defibrillator was medically necessary. The Plan 
denied your request. The Plan says the record shows the enrollee was an inpatient at a facility at the time the 
defibrillator was provided.  separate payment is not permitted. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the defibrillator was used in a SNF or hospital. Therefore, we decided that the Plan does not 
have to pay for an automated external defibrillator (K0606) provided March 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3330) and after-hours office visit 
(D9440) provided on March 2, 2020. 
 
You asked the Plan to pay for endodontic therapy (D3330) and after-hours office visit (D9440). You say that 
you were informed your dental benefit amount covered most regular procedures as well as preventive. You say 
that you were unable to look up benefits yourself. The Plan denied your request. The Plan says the services are 
not covered 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 
endodontic therapy (D3330) and after-hours office visit (D9440) provided on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on April 3, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says 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, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11.  It is noted multiple attempts were made to obtain 
additional information from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim cannot be paid as billed due to 
errors with the POS code. Medicare rules for coverage of this service have not been met. Therefore, we decided 
that the Plan does not have to pay for lab services provided to the enrollee on April 3, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for dialysis services provided from October 1, 2019 to October 31, 2019.

You asked the Plan to pay for dialysis services. You say that this provider is certified for Medicare. The Plan denied your request. The Plan says that there are no active rates for this provider.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the record does not confirm that the provider in this case was not participating or excluded from Medicare coverage for the dates of service at issue. The provider appears to have been active with Medicare for the dates of service at issue. The Plan indicates that there are no active rates for this provider, but the documentation provided by the Plan does not corroborate this rationale. We do not find the Plan denial to be substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for dialysis services provided from October 1, 2019 to October 31, 2019. 

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided to the enrollee on March 18, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says The Plan says this is an administrative determination for coding and is not based on clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant360 requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field.

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 claim is missing the main code and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided to the enrollee on March 18, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $120 copayment for emergency room services.  
 
You asked the Plan to waive these services. You say that you cannot afford this bill. The Plan denied your 
request. The Plan says this copayment was charged based on the Plan contract agreement. 
 
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 $120 
copayment for emergency room services. 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 $120 copayment for emergency room 
services provided on March 25, 2020.