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 by a participating provider on February 4, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that the doctor wanted you to be transported. You say that you should not have to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $225 copayment for ambulance services/ground ambulance services. You have been asked to pay a $225 copayment for ambulance services. An ambulance trip was provided; therefore, the correct copayment has been applied. Ambulance services falls within the ambulance
services/ground 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 by a participating provider on February 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on August 24, 2019.

You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1. The Plan denied your request. The Plan says with the information we have, we cannot determine whether the services are necessary. All providers are required to furnish necessary information to the health Plan when requested.

The Plan must follow Medicare rules. Medicare rules say that the provider 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. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on August 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation (E0730) electrical stimulator supplies, 2 lead, per month (A4595) provided February 19, 2021.

You asked the Plan to pre-approve the TENS device and supplies. You say that please review the attached documents and process the claim towards payment. The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria and this request is not reasonable and 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 TENS device and supplies. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee has a diagnosis of chronic pain. The requested device including supplies is not a Medicare covered benefit for chronic pain. The medical records provided do not meet the requirements listed in the NCD/PIM for Medicare coverage. 

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 TENS device and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation (E0730) electrical stimulator supplies, 2 lead, per month (A4595) provided February 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on
February 2, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
service.

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 testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that the enrollee has established coronary artery disease (CAD) and is being treated for this. Cardiac
gene variant testing has limited clinical application at present and is occasionally useful in more rare familial
inherited cardiac conditions like cardiomyopathies and long QT rhythm disorders. This enrollee has established
CAD and should be treated per published conventional secondary prevention guidelines for cholesterol and
blood pressure control. Unless there was very early onset disease or a severe dyslipidemia where an inherited
familial hypercholesterolemia is highly suspected (and no records are provided that speak to that), cardiac gene
variant testing for coronary artery disease is not currently recommended for general risk stratification or family
genetic profiling in an older patient with conventional CAD and risk factors.

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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for the cardiovascular risk assessment panel provided on February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the core buildup (D2950) and endodontic therapy (D3320) provided on March 16, 2021.
You asked the Plan to pay more toward the core buildup (D2950) and endodontic therapy (D3320). You say that the dental insurance was purchased for these procedures and you were informed 50% payment would be applied. You say that you expected insurance payment. The Plan denied your request. The Plan says the claim reprocessed to partially pay for the endodontic therapy and core buildup is only covered when received with a crown.
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 Plan covered the endodontic therapy as a onetime exception at 50%. The core buildup is not a covered benefit because it was not performed together with a crown. Therefore, we decided that the Plan does not have to pay more toward the core buildup (D2950) and endodontic therapy (D3320) provided on March 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for a carotid ultrasound.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says there was no physician order provided.
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
an out-of-network referral for a carotid ultrasound.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee is getting weaker and is not ambulating 250 feet. You say that the enrollee is a severe fall risk. You say that the enrollee cannot stay in the hospital and needs the next level of care. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee can receive the care needed in another setting.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for diarrhea. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at an independent to supervision/contact guard level with functional mobility, including gait to 100 feet x2 with a straight cane. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. While there are identifiable skilled therapy service needs, they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on April 29, 2021.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says eye refractions are only covered by your Plan if performed as a routine screening. The eye refraction was performed for age-related nuclear cataract which is considered a medical reason.

Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.

We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the paring/cutting of benign hyperkeratotic lesions you received at your podiatrist's office on April 15, 2021.

You asked the Plan to waive the deductible for the paring/cutting of benign hyperkeratotic lesions. You say that you do not believe this deductible applies to this service because it was specialist care. The Plan denied your request. The Plan says you were charged this deductible correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible which applies to services performed in a specialist's office. The Plan deductible does not apply to specialist visits, but it does apply to additional services performed in the specialist's office. 

We looked at the documentation in your file. While it is true that the deductible doesn't apply to specialist visits, it does apply to additional services beyond the visit that you receive in the specialist's office. In this case, the paring/cutting of hyperkeratotic lesions is an additional service beyond a regular visit for which the deductible apples. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to additional services performed in a specialist's office. This cost sharing is a contractual obligation that had not been met at the time the paring/cutting of benign hyperkeratotic lesions was received on April 15, 2021.

Therefore, we decided that the Plan does not have to waive the deductible for the paring/cutting of benign hyperkeratotic lesions you received at your podiatrist's office on April 15, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for nebulizer, with compressor provided on June 15, 2020.
You asked the Plan to pay for nebulizer, with compressor (E0570). You say that the claim was timely. The Plan denied your request. The Plan says that the claim was processed correctly, and documentation supplied did not support adjustments.
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 has not provided a Summary, Remittance, Notice of Denial, proof of delivery or medical records. Therefore, we decided that the Plan has to pay for nebulizer, with compressor provided on June 15, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, x-rays and electrical stimulation provided on March 30, 2021.

You asked the Plan to pay for the office visit (99202), x-rays (72070, 72100, 72040) and electrical stimulation (G0283). You say that the benefits for the x-rays were misquoted by the Plan. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the services at issue are not manual manipulation of the spine. Therefore we decided that the Plan does not have to pay for the office visit, x-rays and electrical stimulation provided on March 30, 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
February 22, 2021.
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 February
22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on May 12, 2021.
You asked the Plan to pay for the dental services. You say that you asked for only covered services. The Plan denied your request. The Plan says periapical x-rays are not listed as covered services.
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 periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an expandable controller (E2377, E2313), a privacy flap
(K0108), and a footplate connector (K0108).
You asked the Plan to pay for an expandable controller a privacy flap, and a footplate connector. You say that
the enrollee needs these items. The Plan denied your request. The Plan says these items are not necessary.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is
medically necessary for any of the functions described in the Local Coverage Article. Miscellaneous options,
accessories, or replacement parts for wheelchairs that do not have a specific code and are not included in
another code should be coded K0108.
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 an expandable controller a privacy flap, and
a footplate connector. Our reviewer says that the requirements for coverage of the requested items have not
been met. Our physician reviewer found the patient's strength in the left upper extremity with the ability to feed
himself supports that the patient can control any power options through their own individual switches, meaning
the expandable controller is not medically necessary. The privacy flap and footplate connector cannot be
approved because they were requested with code K0108, which is to be used when there is not a more specific
code for an item. There are more specific codes for these items.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an expandable controller a privacy flap, and a footplate connector have not been
met. Therefore, we decided that the Plan does not have to pay for an expandable controller (E2377, E2313), a
privacy flap (K0108), and a footplate connector (K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically
necessary. The Plan denied your request. The Plan says the current plan of care is restorative, and your
conditions have not shown objective clinical improvement with respect to function or reduction of complexity
of the condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 ten (10) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally
accepted as specific and effective therapy for your condition beyond what was approved by the health Plan.
You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist
are required to safely and effectively provide treatment, that the services can be safely and effectively
performed only by a therapist, or by or under the supervision of a therapist. You have been given additional
therapy to be instructed in a home exercise program. The requested services are not part of a maintenance
program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design
and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve ten (10) additional PT visits.