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

We decided that the Plan does not have to pay for paramedic intercept services provided on March 20, 2021.
You asked the Plan to pay for paramedic intercept. You say that you have ambulance benefits, and these services were medically necessary. The Plan denied your request. The Plan says these services are not covered by Medicare.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances.
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic intercept services provided on March 20, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda and Paclitaxel.
You asked the Plan to pre-approve Keytruda and Paclitaxel. You say that this drug regimen is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the requested drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda and Paclitaxel. Our reviewer says that the requested drug regimen is not medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has a diagnosis of metastatic triple negative breast cancer, currently PDL-1 negative. The Food and Drug Administration has not stated that the requested drug regimen is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug regimen in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review.
The elements of the coverage criteria 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 Keytruda and Paclitaxel have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda and Paclitaxel.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to pay for medical services provided to the enrollee on January 20, 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 claim has place of service and professional and technical code errors preventing payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, there are technical errors submitted on the claim that must be corrected to allow payment. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on January 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from March 21, 2019, through March 22, 2019, and billed with principal procedure code 02HA3RJ.
You asked the Plan to pay for the inpatient hospital care as billed. You say that the documentation supports the inpatient hospital care as billed. The Plan denied your request. The Plan says the documentation in this case does not support the principal procedure code as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with principal procedure code 02HA3RJ, defined as insertion of short-term external heart assist system into heart, intraoperative, percutaneous approach. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital care as billed. Our reviewer says that the inpatient care as billed is not supported by the medical documentation submitted. Our physician reviewer found that the reviewed documentation indicates the enrollee, a 79-year-old female presented with shortness of breath, was sent to the Cath Lab and was noted to have an occluded left internal mammary artery (LIMA) to left anterior descending artery (LAD) within stent stenosis is noted. This was treated. Patient also noted to have acute on chronic systolic congestive heart failure, this major complication or comorbidity is not supported, no IV diuresis was done, only treated with home dose of Lasix, and no brain natriuretic peptide was noted. The procedure noted that an Impella device was used and removed at the end of the procedure. Per guidelines, when the device is removed at the end of procedure, only the monitoring is coded. Remove procedure code 02HA3RJ, and code 5A0221D, drives the DRG correctly to 217. The review has determined that the medical documentation did not support the principal procedure code 02HA3RJ as billed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from March 21, 2019, through March 22, 2019, and billed with principal procedure code 02HA3RJ
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker purchased June 1, 2021.
You asked the Plan to pay for this equipment. You say that the Plan should pay for this walker. The Plan denied your request. The Plan says you did not have prior authorization to purchase out of network equipment.
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 contract also states durable medical equipment requires prior authorization. This equipment was purchased out of network without approval from the Plan. Therefore, we decided that the Plan does not have to pay for a walker purchased June 1, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and intraoral periapical x-ray (D0220) provided on August 19, 2021.
You asked the Plan to pay for the dental x-rays. You say that this care was provided to evaluate emergency dental pain and should be covered under your medical benefits. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) and intraoral periapical x-ray (D0220) provided on August 19, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for podiatry services you received on July 27, 2021.
You asked the Plan to waive the deductible for the podiatry services. You say that you met your deductible prior to these services. You said that you received a notice from Medicare confirming that your deductible had been met. The Plan denied your request. The Plan says you had not yet met your deductible at the time of these services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $203 deductible which applies to all medical services except for preventive services, Part B drugs, diabetic supplies, emergency room visits, emergency ambulance, urgent care, applicable rides, renal care, and lab services. The deductible notice you received was from Original Medicare, not your health plan. Your health plan has its own deductible that must be met before services are covered. Records show that you had not paid anything towards your $203 health plan deductible prior to these services. The total allowed amount for the podiatry services you received was $252.39. You were assessed the $203 deductible, and then after that was met, you were charged your applicable $30 copayment for podiatry services. The deductible applies to all medical services except for preventive services, Part B drugs, diabetic supplies, emergency room visits, emergency ambulance, urgent care, applicable rides, renal care, and lab services.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible which applies podiatry services. This cost sharing is a contractual obligation that had not been met at the time the podiatry services was received on July 27, 2021. Therefore, we decided that the Plan does not have to waive the deductible for podiatry services you received on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transplant related lodging, meals and transportation (S9975) provided from January 23, 2020, through June 24, 2020.
You asked the Plan to pay for transplant related lodging, meals and transportation. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says the claim for these services has been filed after timely filing limitations.
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 transplant related lodging, meals and transportation was not filed until July 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 transplant related lodging, meals and transportation (S9975) provided from January 23, 2020, through June 24, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation services provided on
March 1, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was not billed according to guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code A0429 is ambulance service, basic life support, emergency transport. This code was billed with the -QL modifier. We find that CPT code A0429-QL is not supported in the medical record. The records show that the enrollee was found unresponsive. She was cool to the touch and rigor was setting. The records do not indicate the enrollee died after the ambulance was called, but before the ambulance arrived. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation services provided on March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and core buildup (D2950) provided on June 21, 2021.
You asked the Plan to pay for the crown and core buildup. You say that you did not know that your dental care would exceed your annual maximum and you still need additional services this year. The Plan denied your request. The Plan says you have met and exceeded your $2,500 annual allowance and no further payment will be made for dental care. In addition, a core buildup is not covered by your benefit.
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 does not cover services that are not listed in the dental benefits chart in the contract. There is a $2,500 annual maximum for supplemental preventative and supplemental comprehensive dental care. Though the Plan offers a dental benefit in excess of Medicare coverage, the items or services exceed the dental benefit's maximum allowance for the 2021 Plan year. In addition, the core buildup is not listed as a covered service. Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and core buildup (D2950) provided on June 21, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the head you had on December 28, 2020. Records show that this service was ordered by the Provider
You asked the Plan to waive the copayment for the CT scan. You say that you did not receive these services. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this test ($106.95) is less than your copayment obligation, you are responsible for the full allowed amount. The Plan says that they contacted the facility and confirmed that these services were provided.
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 $275 copayment for advanced imaging services at an outpatient hospital facility.
You have been asked to pay a $275 copayment for the CT scan. The CT scan falls within the advanced imaging services at an outpatient hospital facility 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 computed tomography (CT) scan of the head you had on December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on July 10, 2021.
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says Original Medicare does not cover routine eye exams (eye refractions) for eyeglasses/contact even when done in connection with otherwise covered diagnosis or treatment of illness or injury. In addition, based on the documentation received, there is no indication that any attempt was made to obtain prior authorization for the out-of-network services.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file and the Plan's rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on July 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 21, 2021.
You asked the Plan to pay for these services. You say that this service should be covered by the Plan. 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 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided to the enrollee from May 4, 2021 to May 20, 2021.
You asked the Plan to pay for this device. You say that treatment with this device was medically beneficial to the enrollee. The Plan denied your request. The Plan says the enrollee was treated with CPT E0675 (Pneumatic Compression Device) for 2 weeks post-operatively. There is no history of lymphedema, venous insufficiency, stasis ulceration, or peripheral vascular disease of the left arm. Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that a pneumatic compression device coded as E0675 is not eligible for reimbursement. The enrollees did not have a medical condition for which this device is covered at the time of treatment. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided to the enrollee from May 4, 2021 to May 20, 2021
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on December 11, 2019.
You asked the Plan to pay for genetic testing provided to the enrollee. You say that this testing was medically necessary and should be covered by the Plan. The Plan denied your request. This testing was requested based on the enrollee's family history of heart disease. However, the results of the testing would not have affected how the enrollee's treatment would be going forward.
The Plan follows Medicare rules. The rules explicitly say that screening tests are not covered. This testing was done for screening purposes due to family history. The outcome of this testing would not determine a change of the course of treatment. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on December 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve the MRI. You say that the records provided support the need for the requested MRI. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our reviewer says that the requested MRI is not medically reasonable and necessary at this time. Our physician reviewer found there is no documented adequate trial of physical therapy for low back pain. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the myocardial perfusion imaging and
stress test you had on March 4, 2021, and the cardiology office visits you had on February 12, 2021, and
March 18, 2021.
You asked the Plan to waive the cost sharing for the myocardial perfusion imaging, the stress test, and the
cardiology visits. You say that you were never advised that there would be charges for these services. You said
that you cannot afford these bills. The Plan denied your request. The Plan says you were charged these
copayments 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 $100 copayment for nuclear medicine services, and a $5 copayment for other services with a specialist. You have been asked to pay a $100 copayment for the myocardial perfusion imaging, a $5 copayment for the stress test, and a $5 copayment for each of the cardiology visits. The myocardial perfusion imaging falls within the nuclear medicine services benefit category. For all of the other services, they each were services with a specialist. 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 cost sharing for the myocardial perfusion imaging and stress test you had on March 4, 2021, and the cardiology office visits you had on February 12, 2021, and
March 18, 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 31, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the claim should be covered because you fell, and no one could help you up. You say the ambulance crew helped you up and checked your blood pressure and nothing was wrong so there was no need to go to the hospital. The Plan denied your request. The Plan says if an ambulance is called and you received care, but decide not to be transported to a hospital, we do not cover those services.
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 31, 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 31, 2021