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

 We decided that the Plan does not have to pay for air ambulance services provided on December 31, 2020.  You asked the Plan to pay for air ambulance services. The Plan denied your request. The Plan says the medical necessity for emergency medical air transport at the member's request is not supported by the information made available for review. Therefore, it is not reasonable or necessary, ground transportation certainly would have been another option if necessary and therefore does not meet coverage requirements of either Medicare or the funds.  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 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 air ambulance services. Our reviewer says that air ambulance services are not medically necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has weeping lower extremity edema. The record indicated that the enrollee requested air transportation. The records provided do not demonstrate the enrollee's medical condition needed immediate and rapid ambulance transport that could not have been provided by ground ambulance. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services provided on December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Corus CAD Assay provided to the enrollee on  September 10, 2020.  You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says this service is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that the Corus CAD Assay does not meet Medicare's reasonable and necessary criteria for coverage.          Medicare and the plan do not consider the denied test to be reasonable or necessary. 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 for the Corus CAD Assay provided to the enrollee on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided the Plan does not have to pay for chiropractic services provided from June 28, 2021 to July 14, 2021.  You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the services billed by your provider are not covered by Medicare.  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. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from June 28, 2021 to July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on March 10, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes place.  We looked at the file and Medicare rules. In this case, the records show that the enrollee was an inpatient when the lab services were provided. This means that it is inappropriate to bill an outpatient place of service code (22) for the lab services. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ondansetron 8 mg tablet.  You asked the Plan to pre-approve Ondansetron. You say that this requested drug is medically reasonable and necessary. The Plan denied your request. The Plan says this drug is not among those covered under the enrollee's medical benefit.    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. Specifically, although certain oral anti-emetic drugs are covered, the criteria for coverage in this case have not been met as these drugs are not being initiated within two hours of the administration of cancer chemotherapy for a period to not exceed 48 hours. Therefore, we decided that the Plan does not have to pre-approve Ondansetron 8 mg tablet.   Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740).  You asked the Plan to pre-approve a crown. You say that the crown that needs to be replaced is very old and the enrollee is having sensitivity and aches under and around the crown. The Plan denied your request. The Plan says the requested crown is not medically necessary. The Plan also says that the tooth does not appear to have significant breakdown due to decay or trauma.  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 Plan covers a crown when the services are medically necessary and reasonable.   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 a crown. Our reviewer says that the service is not medically necessary. Our physician reviewer found the record does not indicate pathologic destruction to the tooth by caries or trauma involving 4 or more surfaces and at least two cusps. The elements of the coverage rules are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675).  You asked the Plan to pay for a pneumatic compression device. You say that the item should be covered. The Plan denied your request. The Plan says this is not a covered item.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories 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 this is not medically necessary.  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.  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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no qualifying diagnosis for a group 3 power wheelchair of a neurological condition, a myopathy, or a congenital skeletal deformity. Therefore, the requested Group 3 power wheelchair and accessories is not medically 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a CORUS coronary artery disease (CAD) test (81493) provided on August 13, 2020.  You asked the Plan to pay for a Corus CAD Test. You say that this was covered at the time of service. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. Medicare rules say that the CORUS CAD test will be considered reasonable and necessary for patients with stable symptoms that have a history of chest pain, suspected anginal equivalent to chest pain, or a high risk of CAD, but no known prior myocardial infarction or revascularization procedures. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. Medical records apart from the order and results have not been submitted to show that the criteria for coverage have been met.Based on this information, we decided that Medicare rules for coverage of a Corus CAD Test have not been met. Therefore, we decided that the Plan does not have to pay for a CORUS coronary artery disease (CAD) test (81493) provided on August 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 16, 2021.  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 the enrollee did not have prior authorization for out-of-network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (CPT code(s): A4657, J2501, 82435, 85027, 84520, 84520-91, 84295, 84155, 84132, 84100, 84075, 82565, 82374, 82310, 82040, J1756 and J0887-JB) provided to the enrollee from March 1, 2021, through March 31, 2021.  You asked the Plan to pay for the services. You say that you would like the Plan to reprocess this as one claim and not two (2) separate claims. The Plan denied your request. The Plan says the services are not covered as billed.  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 services have not been met. Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure.  Additionally, per the Medicare Claims Processing Manual, Chapter 8, Section 10, the following is stated: "Effective January 1, 2011 Section 153b of the Medicare Improvements for Patients and Providers Act (MIPPPA) requires the implementation of an end-stage renal disease (ESRD) bundled prospective payment system (ESRD PPS). The ESRD PPS provides a single payment to ESRD facilities that will cover all of the resources used in furnishing an outpatient dialysis treatment, including supplies and equipment used to administer dialysis (in the ESRD facility or at a patient's home), drugs, biologicals, laboratory tests, training, and support services." Therefore, no additional payment will be made for supplies, equipment, drugs, biologicals, laboratory tests, training, or support services provided with outpatient hemodialysis. Therefore, we decided that the Plan does not have to pay for the services (CPT code(s): A4657, J2501, 82435, 85027, 84520, 84520-91, 84295, 84155, 84132, 84100, 84075, 82565, 82374, 82310, 82040, J1756 and J0887-JB) provided to the enrollee from March 1, 2021, through March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyewear provided on June 10, 2021.  You asked the Plan to pay for eyewear. You say that you were understanding that your Plan benefits would reset at the beginning of the 2nd year, like many of your other benefits. The Plan denied your request. The Plan says you previously received eyewear on October 4, 2019. Your routine vision benefit is administered on a rolling calendar year since your last date of service, you are eligible for your routine vision allowance ever two years.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and the Plan's rules. The file shows that you received the eyewear benefit on  October 4, 2019. The routine vision benefit is administered on a rolling calendar year; therefore, you are not eligible for coverage of eyewear until June 10, 2021. Based on this information, we decided that the Plan's rules for coverage of eyewear have not been met. Therefore, we decided that the Plan does not have to pay for eyewear provided on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on July 9, 2021.  You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says the Plan does not offer reimbursements for hearing aids or services purchased out-of-network.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when you see the Plan's hearing aid provider.  We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on  July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial hospital care, per day (99223) provided November 6, 2019.  You asked the Plan to pay for the hospital services. You say that please note you did not receive proper notice of this enrollee's benefit determination, hence the untimely submission of the claim. The Plan denied your request. The Plan says the claim was submitted past the timely filing limitation.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for the hospital services was not filed until May 20, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the initial hospital care, per day (99223) provided November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided on October 16, 2020, to October 28, 2020.  You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says at the time of service, this provider was not in-network, and you did not have prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. Therefore, we decided that the Plan does not have to pay for out of network physician services provided on October 16, 2020, to October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pulpal debridement (D3221) provided on July 13, 2021.  You asked the Plan to pay for the dental service. You say that you had a root canal done and it became infected. You say that you were in a lot of pain and had swelling. You say that you were given 2 treatment options. You also say that you chose the cheaper one in hopes of getting it covered. The Plan denied your request. The Plan says pulpal debridement is not listed as a covered service.  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 pulpal debridement is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulpal debridement (D3221) provided on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on July 29, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The 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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the drug testing provided on July 29, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the services you require can be provided at a lower level of care at a different setting.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on June 23, 2021.  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 covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services (00400) provided on June 4, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not billed with an appropriate diagnosis code.  The Plan must follow Medicare rules. Medicare rules say that only certain diagnosis codes are allowed for coverage of code 00400.   We looked at the file and Medicare rules. Per LCA A57361, code 00400 must be billed with an appropriate diagnosis code for coverage to be considered. Diagnosis code N42.9 is not listed as an appropriate diagnosis code for the requested anesthesia services. 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 for the anesthesia services (00400) provided on June 4, 2021.