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

 We decided that the Plan does not have to waive the copayment for ambulance services provided on September 27, 2021.  You asked the Plan to waive the copayment for ambulance services. You say that the hospital was not able to care for you so you were sent to another hospital. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $230 copayment for ambulance services.   You have been asked to pay a $230 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for hearing aids provided on September 17, 2021.  You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says hearing aids are covered through the Plan's hearing vendor network to utilize the benefits.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on September 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 14, 2021.  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 the appropriate modifier was not 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, we have confirmed that code 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on September 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided the Plan does not have to pay for emergency response with no transport provided on August 15, 2021.   You asked the Plan to pay for these services. You say that you did not call 911 and you believe the Plan should pay for these services. The Plan denied your request. The Plan says the rules are clear that these services are not covered by Medicare.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The records show the ambulance company did not provide transport services on August 15, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for emergency response with no transport provided on August 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve outpatient mental health visit to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve outpatient mental health visit. You say that you interviewed the member of and you are appealing with supporting records. The Plan denied your request. The Plan says there are in-network providers who could have seen the member in a timely fashion, and these services do not require a specialized 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.       The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The member continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation doesn't support that she would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his/her functional status. The member is ambulating up to 100 feet with minimal assistance. She is near her prior level of function and can receive services 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye refraction (92015) provided on July 13, 2021, with a medical eye exam.  You asked the Plan to pay for the eye refraction. You say that you were referred to this provider by your primary care provider for a diabetic eye exam. You say this service is always part of this exam, which you receive regularly. The Plan denied your request. The Plan says eye refractions are not covered by your plan or by Original Medicare.  The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. 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.  The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on July 13, 2021, with a medical eye exam.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve two guided tissue regenerations (D4266 x2), two interim implant abutment placements (D6051 x2), and two bone replacement grafts for ridge preservation (D7953 x2).  You asked the Plan to pre-approve the guided tissue regenerations, interim implant abutment placements, and bone replacement grafts. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit plan.  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 pre-approve two guided tissue regenerations (D4266 x2), two interim implant abutment placements (D6051 x2), and two bone replacement grafts for ridge preservation (D7953 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network chiropractic care provided to the enrollee
from August 4, 2021, to August 18, 2021.
You asked the Plan to pay for out of network services. You say that you did not realize your office was out of
network for the enrollees HMO 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 has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. You are 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
chiropractic care provided to the enrollee from August 4, 2021, to August 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Denosumab.  You asked the Plan to pre-approve Denosumab. The Plan denied your request. The Plan says the enrollee is not using an aromatase inhibitor.  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 Denosumab. Our physician reviewer found that in this case, the record indicates that the enrollee has a diagnosis of bilateral breast cancer and anal cancer. The record does not indicate that the enrollee is receiving an aromatase inhibitor. The record provided is insufficient to establish that the enrollee's clinical condition matches any medically accepted indication for the use of the requested drug. The FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Denosumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Denosumab.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services performed by a qualified physical therapist (G0151) and home health care provided in patient's home/residence (Q5001) provided on March 10, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the services performed by a qualified physical therapist and home health care provided in patient's home/residence. You say that the services provided were medically necessary and you would like this claim to be reprocessed. The Plan denied your request. The Plan says there is no referring provider for the enrollee. The Plan also says that the services were not authorized by network/primary care providers.

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 services performed by a qualified physical therapist (G0151) and home health care provided in patient's home/residence (Q5001) provided on March 10, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62320) provided September 20, 2021.
You asked the Plan to pay for the injections. You say that the injections were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. No clinical records were submitted to support the billed services.
Based on this information, we decided that Medicare rules for coverage of the injections have not been met.
Therefore, we decided that the Plan does not have to pay for injections (62320) provided September 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the lumbar spine provided on August 4, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you feel that the Plan should pay the bill since you are on social security and already pay thousands for insurance. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for diagnostic and nuclear medicine radiological services performed at a contracted facility. You have been asked to pay a $150 copayment for the MRI. The 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 magnetic resonance imaging (MRI) of the lumbar spine provided on August 4, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ziextenzo.
You asked the Plan to pre-approve Ziextenzo. You say that Ziextenzo is medically necessary. The Plan denied
your request. The Plan says Ziextenzo is a non-preferred product.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Ziextenzo. Our reviewer says that
Ziextenzo is not medically necessary. Our physician reviewer found the requested medication is a new start.
The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one
alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse
effect from the Plan's preferred step one alternative.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ziextenzo have not been met. Therefore, we decided that the Plan does not have
to pre-approve Ziextenzo.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia service (00731) provided on October 1, 2021.  You asked the Plan to pay for the anesthesia service. You say that you would like reconsideration because this claim denied as a duplicate in error. The Plan denied your request. The Plan says this is a claim for duplicate services which have already been processed and paid.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We find that CPT code 00731 is not supported in the record. Specifically, the documentation submitted does not indicate that the provider at issue rendered the anesthesia services. There is insufficient information to verify if Medicare criteria for coverage have been met. Based on this information, we decided that Medicare rules for coverage of the anesthesia service have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia service (00731) provided on October 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on May 29, 2021.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the member
was in hospice on this date of service and traditional Medicare pays for hospice services.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for ambulance services provided on May 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says IRF admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for hemoptysis, respiratory failure, and surgical resection of squamous cell cancer of the neck. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunization services provided to the enrollee on September
23, 2021.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says this is not a covered service.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The
Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the services.
Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on
September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided October 6, 2021.
You asked the Plan to pay for the office visit. You say that the office visit was medically necessary. The Plan
denied your request. The Plan says the claim was billed with an invalid place of service.
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 99204 is not supported in the medical record. Specifically, the office visit was billed
with an invalid place of service (12, home setting). Based on this information, we decided that Medicare rules
for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for
an office visit (99204) provided October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81223, 81302, 81479) provided May 19, 2021.

You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the enrollee had no symptoms and the testing was for screening purposes.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, a pulmonary disease risk panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (81223, 81302, 81479) provided May 19, 2021.