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

We decided that the Plan does not have to pay for embolectomy or thrombectomy, with or without catheter; axillary, brachial, innominate, subclavian artery, by arm incision (CPT code 34101) provided to the enrollee on November 30, 2020.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the clinical documentation provided in the narrative operative report does not sufficiently describe or support the services for CPT code 34101.
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 asked our coder 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 service. Our reviewer found the review indicates that the Thromboendarterectomy services denied because M127 - Missing patient medical record for this service. The clinical documentation provided in the narrative operative report does not sufficiently describe or support the services for CPT code 34101 therefore it's being upheld. The level of service for CPT code 34104 is not
supported in the medical records for the above denied dates of service.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for embolectomy or thrombectomy, with or without catheter; axillary, brachial, innominate, subclavian artery, by arm incision (CPT code 34101) provided to the enrollee on November 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided on January 21, 2021.
You asked the Plan to pay for air ambulance services. You say that air ambulance services were medically
necessary. The Plan denied your request. The Plan says air transportation was not medically necessary. The
enrollee was medically stable for ground transport.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your
medical condition is such that transportation by ground ambulance is not appropriate.
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 air ambulance services. Our reviewer says
that air ambulance services were not medically necessary. Our physician reviewer found that the enrollee is a
70-year-old male who presented to the hospital with abdominal pain, dark stool, for one day. The enrollee's
hemoglobin was10.6, and a computed tomography (CT) scan of the abdomen showed free air. The enrollee
was given proton pump inhibitors (PPI), and antibiotics. He was not in acute distress but was ill-appearing.
Troponin was negative. His vitals were stable. He was transported via air ambulance for a hospital-to-hospital
transfer. Based on the provided records, the enrollee appeared stable enough for ground transport. Ground
transport was expected to be 50 minutes, whereas the air transport was 40 minutes. The documentation does not
support that the enrollee suffers from an illness or injury that contraindicates transportation by any means other
than ambulance. The documentation does not support that the enrollee's condition was such that the time
needed to transport the enrollee by ground, or the instability of transportation by ground, posed a threat to the
enrollee's survival or seriously endangered the enrollee's health. Ground transport would have taken about the
same amount of time and there wasn't sufficient urgency to justify saving 10 minutes for transportation. The
documentation does support that the transferring hospital did not have adequate facilities to provide the medical
services needed by 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 air ambulance services have not been met. Therefore, we decided that the Plan
does not have to pay for air ambulance services provided on January 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiological diagnostic services received on March 3, 2021.
You asked the Plan to waive the copayment for the services. You say that this was a preventive test for future problems. The Plan denied your request. The Plan says cost-sharing is a contractual obligation of the plan, and cannot be waived.
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 $160 copayment for Medicare-covered radiological diagnostic services. 
You have been asked to pay a $160 copayment for the services. The services fall within the Medicare-covered radiological diagnostic 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 radiological diagnostic services received on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Transcutaneous Electrical Nerve Stimulation (TENS) unit (E0730) provided on February 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for a TENS unit. You say that the item is medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for an out-of-network provider.
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 a Transcutaneous Electrical Nerve Stimulation (TENS) unit (E0730) provided on February 15, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services rendered on May 25, 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 that the services are not payable.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan states that the services are not payable under 42 Code of Federal
Regulations (CFR), Section 410.32(a); however, this is the basic rule for diagnostic x-ray services. The services
at issue are diagnostic laboratory services and not x-ray services. The Plan has not provided any documentation
or Medicare rules to support that the services are not payable as rendered and billed. Therefore, we decided that
the Plan has to pay for the laboratory services rendered on May 25, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy provided on January 27, 2021.
You asked the Plan to pay for the home infusion therapy. You say that you were given an extension in the
contract and are not out-of-network. You say that this is billed correctly and should be reviewed. The Plan
denied your request. The Plan says the billed code is not valid for Medicare purposes.
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 S9338 is not supported in the medical record. Specifically, per the Physician Fee
Schedule, CPT code S9338 has a status indicator of I. This means that CPT code S9338 is not valid for
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home
infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home
infusion therapy provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services received from an out-of-network provider on May 19, 2021.
You asked the Plan to pay for the services. You say that you were told that this provider worked with the plan. The Plan denied your request. The Plan says the services were rendered by an out-of-network dental provider.
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 dental services when provided by a network dentist. The rendering dentist is out-of-network. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for dental services received from an out-of-network provider on May 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical and occupational therapy provided
from February 23, 2021, through March 15, 2021.

You asked the Plan to waive the copayment for physical and occupational therapy. You say that physical and
occupational therapy came to the house when you were released. You say that you are appealing the bills from
this provider. The Plan denied your request. The Plan says the copayments applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35
copayment for each Medicare-covered physical therapy and speech-language therapy visit and a $35
copayment for each Medicare-covered occupational therapy visit.

You have been asked to pay a $35 copayment for each physical and occupational therapy visit. The total
amount you owe is $560 ($35/visit x 16 visits = $560). Physical and occupational therapy falls within the
"Outpatient Rehabilitation 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
physical and occupational therapy provided from February 23, 2021, through March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation admission and services provided from February 25, 2021, to March 4, 2021.
You asked the Plan to waive the copayment for the inpatient rehabilitation care. You say that you paid your first hospital copayment for February 17, 2021, to February 25, 2021, and feel this copayment should cover the stay at both facilities as you were transferred from one directly to the other. The Plan denied your request. The Plan says inpatient hospital care copayments apply each time you are admitted or transferred. This copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for each of the first six days of inpatient hospital care. There is a $0 copayment for additional hospital days. Your inpatient cost sharing will apply each time you are admitted. This includes when transferring from one facility directly to another or within the same facility between levels of care. You have been asked to pay a $1,950 copayment for inpatient care. Documentation shows that you were transferred on February 25, 2021, and therefore a new copayment applies. 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 inpatient rehabilitation admission and services provided from February 25, 2021, to March 4, 2021.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to pre-approve 2 additional physical therapy visits. We decided that the Plan does
not have to pre-approve the remaining 8 physical therapy visits.
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that it is recommended the
enrollee continue with skilled physical therapy to reduce fall risk, continue to improve pain symptoms and
activities of daily living as well as maximize level of independence. The Plan says additional visits are not
medically necessary.
We decided that the Plan has to pre-approve 2 additional physical therapy visits.
Our reviewer found that the records do not document that the enrollee has been instructed in a home program.
Our reviewer says that two additional physical therapy visits are approved to transition to a home exercise
program Therefore, we decided that the Plan has to pre-approve 2 additional physical therapy visits.
We also decided that the Plan does not have to pre-approve the remaining 8 physical therapy visits.
Our reviewer says that the enrollee appears to have made minimal improvement in strength, range of motion
and pain level with the twenty physical therapy treatments provided thus far. Our reviewer says that further
skilled therapy at this point will not likely achieve any significant improvement in the enrollee's symptoms or
functional status. Therefore, we decided that the Plan does not have to pre-approve the remaining 8 physical
therapy visits.
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 lette
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81455) provided to the enrollee on
December 28, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this cannot be approved.
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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the review indicates that Tempus XT genomic sequencing is not an approved test. The review has
determined that the enrollee does not meet the criteria for this request.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for laboratory services (81455) provided to the enrollee on December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests, consultation and unspecified adjunctive procedure provided on March 26, 2021.
You asked the Plan to pay for the pulp vitality tests, consultation and unspecified adjunctive procedure. You say that the claim was a result of a severe tooth ache that identified the cause as an infection. You say that you realize there is a dollar limit to your policy, but the claim should at least be partially covered. The Plan denied your request. The Plan says the services are not covered benefits and your annual limit of $500 had already been met.
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 pulp vitality tests, consultation and unspecified adjunctive procedure provided on March 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous spacer (22869,
22870).

You asked the Plan to pre-approve the insertion of a Superion interspinous spacer. You say that this is
medically necessary. The Plan denied your request. The Plan says this is experimental.

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 insertion of a Superion interspinous
spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in
this case. Our physician reviewer found current evidence-based medical guidelines and peer-reviewed literature
do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar
laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of
this device for this enrollee's medical 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 the insertion of a Superion interspinous spacer have not been met. Therefore,
we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous spacer (22869,
22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 additional acupuncture treatments.
You asked the Plan to pre-approve the 18 additional acupuncture treatments. You say that you are requesting additional visits because the treatments have been effective in helping you deal with your medical issues and extreme pain you experience. The Plan denied your request. The Plan says your benefit plan limits the number of acupuncture visits per year, and the medical records submitted indicate that you have already received the maximum number of visits allowed this year.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the contract says that you are limited to up to 25 acupuncture visits per year. The record shows that you have received 25 acupuncture visits and your acupuncture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve 18 additional acupuncture treatments.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on January 27 to April 14, 2021.
You asked the Plan to pay for acupuncture services. You say that the treatments and services provided are covered and were provided by in-network doctors. The Plan denied your request. The Plan says rules for payment for acupuncture have not been met.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the case record does not support that the acupuncture services at issue were provided as treatment for CLBP. Therefore, we decided that the Plan does not have to pay for acupuncture services provided on January 27 to April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam and cleaning provided on April 19, 2021.
You asked the Plan to pay for the dental services. You say that your service should be covered. The Plan
denied your request. The Plan says services received from dentists who do not participate in the network are
not covered benefits.
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.
We looked at the file, and Medicare rules. The records indicate the provider at issue is not participating at the
location where the services were provided. Based on this information, we decided that the Plan's rules for
coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for
the oral exam and cleaning provided on April 19, 2021.