Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator.  You asked the Plan to pre-approve an auricular peripheral nerve stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the requested service is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that auricular peripheral nerve stimulation will be denied as noncovered.  This service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary Therefore, we decided that the Plan does not have to preapprove an auricular peripheral nerve stimulator. Therefore, we decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
The enrollee asked the Plan to pay for the ambulance services. The enrollee said that the ambulance services were medically necessary and were required for life-threatening emergencies. The enrollee said that there was no way to predict when their blood sugar levels would suddenly drop. The enrollee stated that the cost of the services were a financial hardship and they asked the Plan to reconsider providing coverage. The Plan denied the enrollee's 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 January 19, 2020 and January 20, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on May 29, 2021, to June 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the inpatient hospital services. You say that you feel the reimbursement was unfair. The Plan denied your request. The Plan says these services were not authorized.  Furthermore, no medical records were provided to justify medical necessity of the services.  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. You did not provide any records to justify payment of this claim. 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 inpatient hospital services provided on May 29, 2021, to June 2, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental extraction (code D7210) you received on July 14, 2021.  You asked the Plan to pay for the dental extraction. You say that your contract says that extractions and oral surgery are covered at 50%. The Plan denied your request. The Plan says this service is not covered under your Plan.  The Plan says that you have not purchased the optional supplemental dental rider.  Extractions (as referenced on page 4-95 of your Evidence of Coverage) are only covered under this optional supplemental rider.  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. This service is covered under the optional dental rider, but you have not purchased this rider. Therefore, we decided that the Plan does not have to pay for the dental extraction (code D7210) you received on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pathology services provided on April 14, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the OON pathology services. You say that these services were medically necessary and ordered by a network provider. The Plan denied your request. The Plan says there was no authorization requested for pathology services in or out of network.   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 pathology services provided on April 14, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home visit provided on May 25, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the home visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  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 home visit provided on May 25, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pneumatic compression device coded E0675 and related accessory (E0673) provided to the enrollee on March 25, 2021.  You asked the Plan to pay for the pneumatic compression device and accessory. You say that this device is medically necessary and should be covered. This device was appropriate to prevent deep vein thrombosis. The Plan denied your request. The Plan says this item is not covered.  The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices coded with E0675 are non-covered. Because this item is statutorily non-covered, any related accessories are also non-covered.  This decision is not a determination of medical necessity or whether or not the item is experimental/investigational.  Rather, this determination is purely an administrative denial based on the explicit wording of the applicable local coverage determination. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and accessory have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device coded E0675 and related accessory (E0673) provided to the enrollee on March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from March 24, 2021, through March 29, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary. The Plan denied your request. The Plan says that the member's past medical history justified observation level of care. Treatment for dehydration and constipation are considered outpatient treatment. There were no acute complications that warrant inpatient level of care.  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 that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department 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 from March 24, 2021, through March 29, 2021.   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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for a PSA test provided on July 7, 2021.  You asked the Plan to pay for a PSA test. The Plan denied your request. The Plan says you have exceeded the maximum benefit allowed by the plan for PSA covered screening and therefore is responsible for the PSA screening services performed on July 7, 2021.  The Plan must follow Medicare rules. Medicare rules say that screening prostate specific antigen tests are covered at a frequency of once every 12 months for men who have attained age 50 (at least 11 months have passed following the month in which the last Medicare-covered screening prostate specific antigen test was performed). We looked at the file and Medicare rules. Medicare rules say that screening prostate specific antigen tests are covered at a frequency of once every 12 months for men who have attained age 50. The file shows that the Plan previously issued payment for a PSA test provided on November 24, 2020, which is within the 12-month limitation. Based on this information, we decided that Medicare rules for coverage of a PSA test have not been met. Therefore, we decided that the Plan does not have to pay for a PSA test provided on July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the monthly supply allowance for a continuous glucose monitor (CGM) provided on May 24, 2021.  You asked the Plan to pay for the monthly supply allowance for CGM. You say that the documentation supports the billed item. The Plan denied your request. The Plan says the LCD criteria are not met. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily administrations. The progress note provided shows that only twice daily insulin is used by the enrollee. Based on this information, we decided that Medicare rules for coverage of the monthly supply allowance for CGM have not been met. Therefore, we decided that the Plan does not have to pay for the monthly supply allowance for a continuous glucose monitor (CGM) provided on May 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance transport provided on  June 21, 2021.  You asked the Plan to waive the copayment for the ambulance transport. You say that you did not have copays this high last year. You say you do not believe this should be your responsibility. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way ambulance trip. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the underarm crutches you received on May 6, 2021.  You asked the Plan to waive the coinsurance for the crutches. You say that you had surgery and when you left the hospital, you were given these crutches.  You said that you didn't want or need them, but you were told it would not cost you anything. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment.   You have been asked to pay 20% coinsurance for the crutches. The crutches fall within the durable medical equipment benefit category. This cost sharing applies regardless of whether or not you used the item. 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 underarm crutches you received on May 6, 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 June 15, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without 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 June 15, 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 June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided the Plan does not have to pay for out of network physician services provided on February 3, 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 you 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 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. 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 February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the assisted living facility visit provided on June 25, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the OON assisted living facility visit. You say that the provider relied on the facility to get the proper authorization. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.    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. Providers are responsible for confirming patients' insurance coverage prior to rendering services. 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 assisted living facility visit provided on June 25, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on August 8, 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 separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.    The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on August 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral exam (code D0150) you had on July 20, 2021.  You asked the Plan to pay for the comprehensive oral exam. You say that you had another dentist, but you became dissatisfied with him.  You stated that you needed a comprehensive oral exam (D0150) to establish yourself with a new dentist. The Plan denied your request. The Plan says you are only entitled to one comprehensive oral exam once every 36 months.  The Plan stated that you already had a covered comprehensive oral exam on January 8, 2020, so you have exhausted this benefit until January 8, 2023.  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.   Your dental benefit explicitly states that comprehensive oral exams (D0150) are only covered once every three years.  This benefit cannot be extended even if you change dentists.  You exhausted this benefit on January 8, 2020, so you are not covered for another one until January 8, 2023, for any reason. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (code D0150) you had on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit received on June 11, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that you were given a referral for these services. The Plan denied your request. The Plan says the services received are not a covered benefit.  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 office visit received on June 11, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from September 4, 2021, through September 8, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that you were admitted to the hospital due to having pneumonia. The Plan denied your request. The Plan says that the supporting documentation did not indicate that the member had low oxygen level, fast heart rate, fast breathing or confusion that did not get better after the observation period. The information available at the time of the decision did not support need for an inpatient stay.  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 that the medical record showed that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier emergency department 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 from September 4, 2021, through September 8, 2021.   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.