Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power wheelchair provided on July 21, 2021.
You asked the Plan to pay for the power wheelchair. You say that the power wheelchair was medically
necessary. The Plan denied your request. The Plan says the provider is out-of-network and not eligible for
Medicare payment.
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 had network providers
available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at
issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the
Plan does not have to pay for a power wheelchair provided on July 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you required contact guard assistance for toilet transfers, to stand up, and to walk 100 feet times two using a two wheeled walker. The documentation does not support that you have documented skilled nursing or skilled therapy needs. You are not shown to have had an acute decline in function. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 31, 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 if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.

We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 31, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee needs rehabilitation to get stronger. The Plan denied your request. The Plan says that the denial of authorization for SNF care is correct.
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 care. Our reviewer says that the enrollee meets criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. However, the enrollee does have skilled therapy needs. The enrollee is functioning below her baseline and has suffered a fall post-operatively. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. The enrollee improving while waiting for her appeal does not justify a denial.
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 care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services provided on June 3, 2021 by an out-of-network (OON) provider.

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 were rendered by an out-of-network provider without 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 requested 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 the telehealth services provided on June 3, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on June 16, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel you should only be charged the copay of $250.00. You also say that the attendants checked you out, everything was okay, and you did not go to the hospital and incur extra charges. The Plan denied your request. The Plan says since there was no transport, the ambulance charges are not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on June 16, 2021. 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 response and treatment with no transport (A0998) provided on June 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on July 10, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that the member did not call the ambulance as someone else in the area did. You say the ambulance personal took her pulse and gave her a band-aid, and they wanted to take her to the emergency room, but she did not want to go. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.

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 July 10, 2021. 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 ambulance response and treatment, no transport (A0998) provided on July 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the private duty nursing services provided from August 11, 2019, to November 8, 2020.

You asked the Plan to reimburse you for the custodial care services provided from August 11, 2019, to September 30, 2020. You say that the services should be covered. The Plan denied your request. The Plan says the enrollee did not receive any skilled medical care during the dates of service. The Plan also says that there was no authorization obtained prior to the services being rendered.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to reimburse you for the private duty nursing services provided from August 11, 2019, to November 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the allograft rendered on June 1, 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 procedure code 20930 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is
always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Billed procedure code 20930 (allograft, morselized, or placement of
osteopromotive material, for spine surgery only [List separately in addition to code for primary procedure)])
has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not
have to pay for the allograft rendered on June 1, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for a physical performance test or measurement provided on
June 11, 2021.
You asked the Plan to pay for a physical performance test or measurement. The Plan denied your request. The
Plan says despite multiple outreaches by the Plan, this provider has not submitted any clinical records to
support the medical necessity of this service.
The Plan must follow Medicare rules. Medicare rules say that the provider 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. The file shows that you did not submit sufficient medical documents
to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of a
physical performance test or measurement have not been met. Therefore, we decided that the Plan does not
have to pay for a physical performance test or measurement provided on June 11, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6539.

You asked the Plan to pre-approve the compression stockings. You say that these stockings are medically necessary because you are a vascular patient. The Plan denied your request. The Plan says this item is not a covered benefit under Medicare.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6539 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 pre-approve compression stockings identified with code A6539.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat sacroiliac joint injections (27096).
You asked the Plan to pre-approve the repeat injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that repeat sacroiliac joint injections are covered when the previous set of injections reduce pain by at least 50% for 6 weeks. 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 repeat injections. Our reviewer says that the requested injections are not medically necessary. Our physician reviewer found the record shows that the enrollee only had limited pain relief for 2 weeks following the previous injections. An additional set of injections 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 repeat injections have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat sacroiliac joint injections (27096).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thyroid genetic testing 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 there is no indication that the results of the testing will directly impact treatment protocol or the management of the enrollee's condition.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found although there was report of atypia on FNA, there was no documented discussion of plans to treat the nodule based on the results of the genetic testing. There was also no report of local institutional malignancy rates to help meet criteria. Therefore, this request for genetic testing will be considered not medically necessary at this time. 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 thyroid genetic testing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on June 25, 2021.
You asked the Plan to pay for the vaccine. You say that you were told that you would be reimbursed. The Plan
denied your request. The Plan says this is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The
Plan follows the same rules.
The records do not show that you have been injured or directly exposed to any illness related to the vaccine.
Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on June 25,
2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve additional routine transportation trips.

You asked the Plan to approve these services. You say that you need transportation to upcoming chemotherapy treatments. The Plan denied your request. The Plan says you have exhausted the benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology services provided to you on August 18, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provided has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dermatology services provided to you on August 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transport - basic life support (A0429) and ground mileage (A0425) provided May 19, 2021.

You asked the Plan to waive the copayment for the ambulance transport and ground mileage. You say that you believe there was a mix-up with the insurance. The Plan denied your request. The Plan says they have confirmed that the provider is billing only the copayment for the ambulance service. The copayment has been applied 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 $290 copayment per date of service regardless of the number of trips by ground or air ambulance.

You have been asked to pay a $290 copayment for the ambulance transport and ground mileage. The ambulance transport and ground mileage fall 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 emergency ambulance transport - basic life support (A0429) and ground mileage (A0425) provided May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 27, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
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. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on May 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 had network providers available who could have provided the services at issue in this appeal.
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 the services provided to you by an out-of-network provider on May 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on June 24, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was no documented contact with the attending/primary care physician (PCP).

The Plan must follow Medicare rules. Medicare rules say that the CP must attempt to consult with the patient's physician within a reasonable time after receiving the consent. 

We looked at the file and Medicare rules. The records provided do not show documentation of the CP's attempt to consult the enrollee's attending/PCP. 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 outpatient mental health services provided on June 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (G0480, 80307) rendered by the out-ofnetwork
(OON) provider on May 18, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without 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 services at issue in this appeal. 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 the drug testing (G0480, 80307) rendered by the out-of-network (OON) provider
on May 18, 2021.