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

We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and ground mileage (A0425) provided on April 9, 2021.
You asked the Plan to pay for the transportation services. You say that the enrollee required 1 to 1 supervision for the duration of transport and assistance on transfers. You also say that the transportation was medically necessary. The Plan denied your request. The Plan says the non-emergency transportation was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 transportation services. Our reviewer says that the transportation services are not medically necessary. Our physician reviewer found the provided documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on April 9, 2021.
The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on April 9, 2021. The documentation did not support that the ambulance transport on April 9, 2021, was medically reasonable and necessary for the enrollee. 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 transportation services have not been met. Specifically, the file does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and ground mileage (A0425) provided on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for special anesthesia services represented by code 99100 billed
for date of service November 20, 2020.
You asked the Plan to pay for code 99100. You say that the medical records provided support the services in
dispute. The Plan denied your request. The Plan says no separate payment is made for code 99100 according to
Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that payment for a code with a status indicator of B is
always bundled into payment for other services.
We looked at the file and Medicare rules. The code which remains in dispute has a status indicator of B. This means that payment for this code is always bundled into payment for other services. Therefore, we decided that the Plan does not have to pay for special anesthesia services represented by code 99100 billed for date of service November 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance transport, advanced life support (A0427), fixed wing air ambulance transport, one way (A0430), specialty care transport (A0434), and fixed wing air mileage (A0435) provided on December 3, 2021.
You asked the Plan to pay for the ambulance services. You say that the claim was done by the provider. You say that they did not finish the claim. You also say that they are out of reach. The Plan denied your request. The Plan says the appeal did not include the Nicaragua hospital records, or the member proof of payment that was requested from the provider. The Plan says that there are no documents regarding payment of the full claim amount, $417,300. The Plan also says that the claim was processed correctly.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.
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 ambulance services. Our reviewer says that the ambulance services are not medically necessary. Our physician reviewer found the documentation did support that the enrollee suffered from an illness or injury that contraindicated transportation by any means other than ambulance. The reviewer found that the documentation did not support that the enrollee's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The reviewer also found that the documentation did not support that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee. Therefore, the reviewer found that the ambulance services were 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 ambulance services have not been met. Specifically, the file did not show that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee. Therefore, we decided that the Plan does not have to pay for the emergency ambulance transport, advanced life support (A0427), fixed wing air ambulance transport, one way (A0430), specialty care transport (A0434), and fixed wing air mileage (A0435) provided on December 3, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve general anesthesia for a tympanostomy.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of chronic rhinitis and nasal septal perforation. A computed tomography (CT) scan demonstrated mild left greater than right fluid within the mastoid air cells bilaterally. The Plan has approved a tympanostomy with local or topical anesthesia.

Minor surgical procedures such as tympanostomy can often be successfully performed under local topical anesthesia. The clinical documentation does not provide a reason that general anesthesia is medically reasonable and necessary in this case. 

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve general anesthesia for a tympanostomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital services.

You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The Plan denied your request. The Plan says the documentation does not support that the criteria for inpatient care are met.

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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met.

Our physician reviewer found the enrollee presented to the hospital with thrombocytopenia. There was no evidence of active bleeding, hemodynamic instability, or plan for a high risk procedure. The records do not show evidence of hypoxemia or active infection and the ultrasound of the abdomen was unremarkable. The records do not support a reasonable expectation that the enrollee would require at least two midnights of inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the abdomen (74153) provided on March 26, 2021.

You asked the Plan to waive the copayment for an MRI. You say that you did not have an MRI performed and that the provider does not know what they are doing. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $325 copayment per day for outpatient diagnostic tests and therapeutic services and supplies that are not ultrasounds.

You have been asked to pay a $325 copayment for an MRI. The EOC confirms that you pay a $325 copayment for diagnostic radiology services such as an MRI or a computed tomography (CT) scan. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies 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 a magnetic resonance imaging (MRI) of the abdomen (74153) provided on March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular disease screening (81407, 81479, 81286, 81408, 81404) provided on April 28, 2021.

You asked the Plan to pay for the cardiovascular disease screening. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing panels.

The Plan must follow Medicare rules. Medicare rules say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular disease screening have not been met. Specifically, the record does not include clinical information to determine why this testing was ordered, how it will affect the member's treatment or if it was ordered for screening purposes. Additionally, this testing was not billed with the appropriate CPT codes for cardiovascular disease screening. Therefore, we decided that the Plan does not have to pay for the cardiovascular disease screening (81407, 81479, 81286, 81408, 81404) provided on April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the vedolizumab injection provided on May 13, 2021.

You asked the Plan to waive the coinsurance for the vedolizumab injection. You say that the infusions were given to you without knowledge of the medication being approved or being notified of how much it would cost. You say that you wouldn't have allowed yourself to begin the infusion knowing the cost that you cannot afford. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B covered drugs from an in-network provider.

You have been asked to pay $1,828.86, which is 20% of the allowed amount for the vedolizumab injection. The allowed amount is $9,144.30 (20% x $9,144.30 = $1,828.86). The vedolizumab injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for the vedolizumab injection provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), and resin-based composite - two surfaces, anterior (D2331) provided June 10, 2021.

You asked the Plan to pay for the dental cleaning, periodic oral exam, and resin-based composite. You say that you did not realize when you removed the dental rider that it would remove all of your dental benefits. The Plan denied your request. The Plan says at the time of services you did not have dental coverage.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), and resin-based composite - two surfaces, anterior (D2331) provided June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) for tooth # 19 provided on March 10, 2021.

You asked the Plan to pay for the dental service. You say that the core build up is medically necessary. The Plan denied your request. The Plan says the core build up is not necessary.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental service when the services are medically necessary and reasonable. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the dental service. Our reviewer says that the core build up is not medically necessary. Our physician reviewer found A review of the documentation indicates that a defective crown on tooth #19 was replaced. The documentation provided did not show that upon removal of the defective crown there was breakdown of the remaining natural tooth structure to warrant a core buildup. Therefore, the reviewer found that the documentation provided was not sufficient to show that a core buildup was medically necessary for tooth #19 prior to placement of a replacement crown. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Specifically, the file does not show that a core buildup was medically necessary for tooth #19 prior to placement of a replacement crown. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) for tooth # 19 provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on May 6, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that you were unable to get an authorization before the service was done. The Plan denied your request. The Plan says services were provided 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit (99214) provided on May 6, 2021, by an out-of-network (OON) provider.
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 records provided support the need for care in a SNF. The Plan denied your request. The Plan says that prior to hospitalization the enrollee was independent in mobility and managing self-care needs. The enrollee is now ambulating 100 or more feet without adaptive equipment, with no loss of balance, and is able to perform transfers without hands-on help.

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 criteria for coverage have been met. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. Given the severity of the enrollee's intracerebral hemorrhage, aphasia and ataxia, daily skilled services are reasonably required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. 

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for removal of recurring cataract in lens capsule using laser (66821) provided on May 5, 2021.

You asked the Plan to waive the copayment for removal of recurring cataract in lens capsule using laser. You say that you were not aware you would be charged a copayment for this procedure. The Plan denied your request. The Plan says the copayment has processed correctly in this case.

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 outpatient hospital services. 

You have been asked to pay a $100 copayment for removal of recurring cataract in lens capsule using laser. This service falls within the outpatient hospital 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 removal of recurring cataract in lens capsule using laser (66821) provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by an opt out provider on November 10, 2020 and November 17, 2020.

You asked the Plan to pay for the dental services. You say that you were never informed that the dentist has opted out of Medicare. You say that it doesn't matter if the provider accepts Medicare with a Medicare Advantage plan and the claim should be approved. The Plan denied your request. The Plan says this dentist is not eligible for payment under Medicare guidelines.

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 the dental services provided by an opt out provider on November 10, 2020 and November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Trilogy Ventilator.

You asked the Plan to pre-approve the Trilogy Ventilator. You say that you would like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 Trilogy Ventilator. Our reviewer says that there is no documentation of CO2 retention on an arterial blood gases. There is no evidence that home BiPAP has been tried. Our physician reviewer found Medicare does not cover a home ventilator used as BiPAP.

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 Trilogy Ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the Trilogy Ventilator.