Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency transportation.
You asked the Plan to pre-approve non-emergency transportation. You say that the member cannot walk far distances and there is no other alternative transportation. You say that you don't understand why this is denied for not being medically necessary. The Plan denied your request. The Plan says the records do not show that you are unable to use other forms of transportation.
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 routine transportation for patients who are not in immediate danger but do require assistance walking or getting into or out of the vehicle. Prior authorization is required. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency transportation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met at a lower level of care.
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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and psychotherapy services (99212 and 90833) provided on February 24, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit and psychotherapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services were rendered out-of-network and were not urgent, emergent or 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 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 and psychotherapy services (99212 and 90833) provided on February 24, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says the mobility deficit will not be significantly improved with the use of this scooter.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 scooter. Our reviewer says that the requested power scooter is not medically reasonable or necessary. Our physician reviewer found the records indicate that this scooter is being requested to go outside, to the local park, and to the store. There is no documentation that your mobility deficit cannot be helped by a cane, walker, or manual wheelchair. The records in fact show that you are using a cane in the home.
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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the somatosensory testing and electroencephalogram services
provided on April 15, 2021.
You asked the Plan to pay for the services provided. You say that you brought your own equipment that is used
to perform the services. The Plan denied your request. The Plan says hospital bundling rules exclude payment
to suppliers of the technical component of a radiology service.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility for services furnished to a beneficiary. The facility must furnish all necessary covered services
to the beneficiary either directly or under arrangements made with outside providers.
We looked at the file and the rules. We find that the services at issue were provided during the enrollee's
inpatient hospital stay. The services were provided via arrangement of the facility. Payment for this service
would have been included under the facility claim. Payment to you for this service is the responsibility of the
facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore,
we decided that the Plan does not have to pay for the somatosensory testing and electroencephalogram services
provided on April 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0651). 
 
You asked the Plan to pay for the intermittent limb compression device. You say that the device was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression 
device (E0651).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer device.
You asked the Plan to pre-approve the Superion interspinous spacer device. The Plan denied your request. The Plan says this is not medically necessary.
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 Superion interspinous spacer device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Superion spacer is experimental. More research is needed to show safety and efficacy of the device.
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 Superion interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services rendered on August 1, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that in the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene, providers report the A0428 (BLS) HCPCS code and modifier QL (Patient pronounced dead after ambulance called) in "HCPCS/Rates" instead of the origin and destination modifier.
We looked at the file and Medicare rules. The file shows that the claim was not billed with procedure code A0428 and the modifier QL. Based on this information, we decided that Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services rendered on August 1, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on July 19, 2021. 
 
You asked the Plan to pay for the prophylaxis (D1110). You say that a prophylaxis is covered 4 times every 
calendar year. You say that this is the second time this has happened this year with the results being you were 
covered. The Plan denied your request. The Plan says a prophylaxis is only covered 2 times every year. 
 
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, you also have a maximum benefit of 2 
cleanings every year. The Plan paid for the prophylaxis provided on January 18, 2021, and April 19, 2021, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis 
(D1110) provided on July 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there are not enough studies on this device to show that it is better than regular spine surgery.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy.
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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (99215) provided January 13, 2021 to February 3, 2021.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says this provider is not eligible for Medicare payment.
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 the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (99215) provided January 13, 2021 to February 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from November 16, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found you did not appear to require inpatient mental health treatment beyond the date in
question as you were not a danger to yourself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. The Plan states it did not appear that active treatment was taking place beyond the date in question. The Plan states it did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis beyond the date in question. Our physician reviewer was unable to find an individualized treatment plan however the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Upon review the records provided for your admission do not meet the criteria for November 16, 2021, forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment while not showing any threats the safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care from November 16, 2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0481) provided April 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the code billed is mutually exclusive to another code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, CPT G0481 was billed with 
G0483. G0481 is mutually exclusive to G0483. 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 lab 
services (G0481) provided April 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 12, 2021.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the code billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on February 9, 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 must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services
were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion
therapy rendered on February 9, 2021.
Benefits for these services 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the plan has no contractual obligation to cover services that are not medically necessary.
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 surgery. Our reviewer says that the requested surgery not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for 1 interspace lumbar (63030- laminotomy (hemilaminectomy), with decompression of nerve roots, including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc is not medically reasonable or 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient cardiac catheterization procedure you had on March 15, 2021, to March 16, 2021.
You asked the Plan to waive the copayment for the cardiac catheterization procedure. You say that your previous insurance covered this in full. You said that this should be treated as outpatient, and not inpatient. The Plan denied your request. The Plan says this service was covered as an outpatient procedure. The Plan says that you were assessed this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 copayment for outpatient surgery and services in an outpatient hospital facility. You have been asked to pay a $175 copayment for the cardiac catheterization procedure. The cardiac
catheterization procedure falls within the outpatient surgery and services in 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 outpatient cardiac catheterization procedure you had on March 15, 2021, to March 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on April 13, 2021.
You asked the Plan to pay for the moderate sedation services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says they have insufficient documentation to corroborate the services billed.
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We looked at the file and Medicare rules. In this case, there was insufficient document to corroborate the services as billed. Without adequate medical records, we cannot confirm these services were performed as billed. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99152) provided on April 13, 2021.