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

We decided that the Plan does not have to pay for the drug testing services (80307 and G0483) provided on February 11, 2021.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration because you are an independent laboratory and cannot send physician reports. The Plan denied your request. The Plan says 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.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We find that CPT code 80307 and G0483 is not supported in the record. Specifically, the claim indicates that this specimen was collected in a laboratory setting, but the record indicates that the member's face-to-face service was rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307 and G0483) provided on February 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance transportation services (A0436, A0431) 
provided on January 19, 2021. 
 
You asked the Plan to pay for the air transportation services. You say that these were emergent, physician 
ordered transportation services for a critically injured enrollee. The Plan denied your request. The Plan says 
Medicare criteria for coverage of air transportation services are not met. The enrollee's vital signs were stable, 
ground transportation was available, and no significant time was saved over ground transportation. 

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the air transportation services have not been met. Specifically, the enrollee is noted as being alert 
with mild distress and not ill-appearing. The location in question was accessible by ground vehicle and no 
obstacles were noted. The distance between the two facilities appears to be a 29-minute, 23.4 mile trip via 
ground transportation. The record shows that there were 27 minutes between the air ambulance's arrivals a both 
facilities. Significant time was not saved between transportation methods. Therefore, we decided that the Plan 
does not have to pay for the air ambulance transportation services (A0436, A0431) provided on January 19, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network physical therapy services.

You asked the Plan to pre-approve out-of-network physical therapy services. You say that he needs physical
therapy services and you have attached the orders from the doctor. The Plan denied your request. The Plan says
services are available with Plan providers.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.

The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is
not providing these services and is not making arrangements to provide these services. Therefore, we decided
that the Plan does not have to pre-approve out-of-network physical therapy services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 services. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Control Linx electronic connection device (E2311) 
and transit option kit (K0108). 
 
You asked the Plan to pre-approve Control Linx and transit kit. You say that the enrollee cannot use the 
wheelchair without these parts. The Plan denied your request. The Plan says the denial of authorization for 
these components is correct, because standard controls are able to accommodate the wheelchair's power 
features and a transit option kit is not covered. 

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules state that for equipment to be covered, it must be appropriate and needed 
for use inside the home. 
 
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 Control Linx and transit kit. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not show that the enrollee requires other types of 
proportional input device or non-proportional input devices. The enrollee does not need to operate 3 or more 
powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant 
control. The enrollee's strength in the upper extremities supports that the enrollee can control any power 
options through their own individual switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Control Linx have not been met. Furthermore, the transit option kit at issue in 
this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan 
covers equipment for use outside of the home. Therefore, we decided that the Plan does not have to pre-
approve a Control Linx electronic connection device (E2311) and transit option kit (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air purifier.
You asked the Plan to pre-approve the purifier. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue 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. Therefore, we decided that the Plan does not have to pre-approve an air purifier.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (920015) provided on May 17, 2021.

You asked the Plan to pay for an eye refraction. You say that you had no knowledge that the eye exam was not covered under your benefit plan. The Plan denied your request. The Plan says you received a diabetic eye exam which is considered to be a medical eye exam.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that an eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider.

We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. An eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (920015) provided on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device
You asked the Plan to pre-approve a high frequency chest wall oscillation device. You say that the enrollee has had an ongoing productive cough and an inability to clear her mucus despite utilizing a flutter valve, therefore, HFCWO with the SmartVest is medically necessary in this case. The Plan denied your request. The Plan says the enrollee has a diagnosis of chronic obstructive pulmonary disease and does not have a qualifying diagnosis that supports the medical necessity of a high frequency chest wall oscillation device.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. The record does not show that you have cystic fibrosis, bronchiectasis, or a covered neuromuscular disease.
This means that you do not have a medical condition for which a high frequency chest wall oscillation devise can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided from February 9, 2020, to February 13, 2020.

You asked the Plan to pay for the services provided. You say that medically necessary services were provided to the enrollee. The Plan denied your request. The Plan says that the condition did not qualify for reporting as the principal diagnosis

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. 

We looked at the file and the rules. The medical records in the Plan's decision do not match the records submitted in the case file. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from February 9, 2020, to 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the home health services. You say that this care is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to provide the care you need.
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 the home health services to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance
transportation (A0428) provided on April 15, 2021, and May 1, 2021, by an OON provider.

You asked the Plan to pay for the ground mileage and ambulance transportation. You say that the ambulance
service was medically necessary for the enrollee. The Plan denied your request. The Plan says these services
require prior authorization and there is no prior authorization on file. The Plan also says that there is no
corresponding facility claim on file.

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
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 ground mileage (A0425) and non-emergent
ambulance transportation (A0428) provided on April 15, 2021, and May 1, 2021, by an OON provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room (ER) services you
received on June 30, 2021, to July 1, 2021.
You asked the Plan to waive the copayment for the ER services. You say that you were admitted to the hospital
because the medication administered in the ER was not working. The Plan denied your request. The Plan says
you were charged this copayment 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 $90
copayment for emergency room services.
You have been asked to pay a $90 copayment for the ER services. While it is true that the copayment for ER
services is waived if you are admitted within 24 hours, you were not formally admitted to the hospital. The
billing records show that you were kept in observation status, which is not the same as an inpatient admission.
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 emergency room (ER) services you received on June 30,
2021, to July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 3 power wheelchair and accessories. 
 
You asked the Plan to provide a Group 3 power wheelchair and accessories. You say that the enrollee has 
mobility limitations and needs a power wheelchair or power mobility device. The Plan denied your request. 
The Plan says the enrollee does not have a qualifying condition. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 

The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy, or congenital skeletal deformity. Therefore, we decided that the Plan does not have to provide a 
Group 3 power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the endodontic therapy (D3330) and limited oral evaluation (D0140), provided on March 8, 2021, and March 10, 2021.
You asked the Plan to pre-approve the endodontic therapy and limited oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says you have exceeded your frequency limitation for oral evaluations, and you received the services out-of-network.
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 pre-approve the endodontic therapy (D3330) and limited oral evaluation (D0140), provided on March 8, 2021, and March 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Gelsyn-3.

You asked the Plan to pre-approve Gelsyn-3. You say that your physician believes this drug is the best one for
you. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because
the Plan requires a trial of Visco-3, Gel-One, Orthovisc, Synvisc, or Synvisc-One before it will approve
Gelsyn-3.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

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 Gelsyn-3. Our reviewer says that you
do not meet the Medicare criteria for a step therapy exception for Gelsyn-3. Our physician reviewer found the
record does not show that you have tried the Plan's preferred drugs of Visco-3, Gel-One, Orthovisc, Synvisc, or
Synvisc-One. The record does not show that these drugs would likely be less effective and/or have adverse
effects for you.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Gelsyn-3.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower level of 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 in the Medicare rules section. 
 
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. 

The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a femur 
fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the documentation does support a need for physical 
and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition 
does not meet Medicare criteria for IRF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751), post and core in addition to crown
(D2954), and endodontic therapy (D3320).

You asked the Plan to pre-approve the crown, post and core in addition to crown, and endodontic therapy. You
say that you need these procedures. The Plan denied your request. The Plan says these services are not covered
under your benefit plan.

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. The Plan offers an optional supplemental benefit that is available for
purchase, but you did not elect to sign up for this benefit. Therefore, we decided that the Plan does not have to
pre-approve a crown (D2751), post and core in addition to crown (D2954), and endodontic therapy (D3320).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on May 12, 2021.

You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges because
you thought you would only owe a $90 emergency room copayment. The Plan denied your request. The Plan
says the claims were processed correctly and you are being charged the correct 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 $225
copayment for advanced imaging.

You have been asked to pay a $225 copayment for a CT scan. A CT scan falls within the outpatient diagnostic
tests and therapeutic services and 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 copayment for a CT scan provided on May 12, 2021.