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

 We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on July 24, 2021.  You asked the Plan to pay for the ground mileage and non-emergency ambulance transportation. You say that this transport was medically necessary. The Plan denied your request. The Plan says on this date of service the enrollee's claims history indicates they were in an inpatient hospital status.  The Plan must follow Medicare rules. Medicare rules say that transportation, including transportation by ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where the patient is an inpatient is covered by the prospective payment rate.      We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ground mileage and non-emergency ambulance transportation have not been met. Payment for the ambulance services in this case is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on July 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after January 27, 2022.  You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care remains medically reasonable and necessary. The Plan denied your request. The Plan says SNF care is no longer medically necessary.  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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, custodial and intermittent, can be provided at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on July 30, 2021.  You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit provided on July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the testing services provided on March 17, 2021.  You asked the Plan to pay for the services provided. You say that the diagnosis is correctly linked with the billed code. The Plan denied your request. The Plan says the screening testing is not a Medicare benefit.  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.  We looked at the file and the rules. The records provided show the testing was ordered as a screening. There are no medical records that indicate the testing was ordered to aid in the treatment of a specific medical treatment or diagnosis. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the testing services provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a specialist office visit (99213) provided on May 28, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a specialist office visit. You say that it would seem that if the hospital is considered an authorized provider, then any service rendered by the house provider would also be included in that authorization. You also say that the patient would have every reason to assume that any provider who is an employee of the hospital would not require a separate authorization. The Plan denied your request. The Plan says the services were billed/rendered by non-participating providers. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a specialist office visit (99213) provided on May 28, 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 an office visit (99214, 93000) provided on August 12, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was 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 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 an office visit (99214, 93000) provided on August 12, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for bathroom safety bars (E0241) and sales tax (S9999), provided on August 5, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for bathroom safety bars and sales tax. You say that the items should be covered. The Plan denied your request. The Plan says the items were purchased from out-of-network durable medical equipment supplier.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you pay 0% coinsurance for bathroom safety equipment upon written prescription from a network provider to a network DME or Orthotics and Prosthetics (O&P) supplier in your PCP's referral circle.  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 bathroom safety bars (E0241) and sales tax (S9999), provided on August 5, 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 the fluoroscopic guidance for needle placement (77002) provided on August 2, 2021.  You asked the Plan to pay for the fluoroscopic guidance for needle placement. You say that this claim has been billed appropriately. The Plan denied your request. The Plan says this claim has been billed without the appropriate primary procedure.  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 the fluoroscopic guidance for needle placement is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement (77002) provided on August 2, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided January 8, 2020, through January 27, 2020, as originally billed by the provider.  You asked the Plan to pay for the SNF care. You say that you believe these services have been billed correctly based on the provided documentation. The Plan denied your request. The Plan says that the information that has been submitted is missing required information necessary for the payment of SNF services as billed.  The Plan must follow Medicare rules. Medicare rules say that SNF services are billed using a HIPPS code which has four digits for four case-mix groups as described in the Medicare rules section.  We looked at the file and Medicare rules. In this case, the Plan has argued that the clinical documentation submitted does not substantiate the services as billed. Specifically, they are arguing that a necessary signature is missing. Upon review, the documentation submitted includes a signed and dated clinical document of the functional assessment that supports the usual function as coded on the Minimum Data Set (MDS). Based on this information, we decided that Medicare rules for coverage of the SNF care have been met. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) care provided January 8, 2020, through January 27, 2020, as originally billed by the provider.   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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and removal of residual tooth roots (cutting procedure) (D7250) provided September 17, 2021.  You asked the Plan to provide additional payment for the surgical tooth extraction and removal of tooth roots. You say that you cannot afford the cost. The Plan denied your request. The Plan says services have been covered up to your dental allowance. The remaining cost over the allowance is not covered.  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 surgical tooth extraction and removal of tooth roots when the services are medically necessary and reasonable.  We looked at the file and Medicare rules. In this case the Plan provided documentation showing that at the time the claim was processed you had $1,474 remaining in your dental allowance. This amount was applied to your claims. You are responsible for the cost above the allowance amount. Therefore, we decided that the Plan does not have to provide additional payment for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and removal of residual tooth roots (cutting procedure) (D7250) provided September 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac joint (SI).  You asked the Plan to pre-approve SI RFA. You say that the enrollee would benefit from radiofrequency ablation (RFA) of the sacroiliac (SI) joint. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the records do not show that the enrollee's pain is localized to the neck or back and does not travel to other areas of the body.  The Plan follows Medicare rules. Medicare rules state that therapeutic radiofrequency ablation (RFA) procedures may be covered if certain criteria are met.  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 SI RFA. Our reviewer says that the enrollee does not meet the Medicare criteria for SI RFA. Our physician reviewer found on October 16, 2020, the enrollee had a diagnostic left sacroiliac (SI) joint injection which provided no relief. On December 10, 2020, he had another injection that provided only 3 hours of relief. The lack of sustained pain relief from the diagnostic injections does not support the diagnosis. This request is not medically reasonable and 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 SI RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac joint (SI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for oxygen DME (E1390, E0431) and a wheelchair (K0001) provided on July 10, 2021, and July 20, 2021.  You asked the Plan to waive the coinsurance for the oxygen DME and wheelchair. You say that the services should be covered for the enrollee. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Durable Medical Equipment (DME) and Related Supplies.    The enrollee has been asked to pay a 20% coinsurance for oxygen equipment (the total allowed amount is $130.99 x 20% = $26.2), and 20% coinsurance for a wheelchair (the allowed amount is $30.52 x 20% = $6.10) for a total cost-sharing of $32.3. Oxygen equipment and wheelchairs fall within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for oxygen DME (E1390, E0431) and a wheelchair (K0001) provided on July 10, 2021, and July 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the thorax provided on August 20, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that your provider informed you that they did not have the facility for a CT scan, so you had to go to another location. 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 $250 copayment per visit for outpatient diagnostic and therapeutic services and supplies, such as CT scans.    You have been asked to pay $165.46, which is less than the $250 copayment for the CT scan. CT scans fall 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 computed tomography (CT) scan of the thorax provided on August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on May 22, 2021 by the out of network dentist.  You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says dental services received out of network are not covered.  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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on May 22, 2021 by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve service dog supplies to be provided by a participating provider.  You asked the Plan to pre-approve service dog supplies. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the provider failed to submit medical records to verify that a service dog is medically necessary.  The Plan must follow Medicare rules. Medicare rules say that your health care provider must confirm that you have a qualifying chronic condition as defined by the Centers for Medicare and Medicaid (CMS) guidelines for Supplemental Benefits for Chronically Ill Enrollees (SSBCI), and your dog must meet the definition of a service animal under the Americans with Disabilities Act (ADA). Service animals are defined under the Americans with Disabilities Act (ADA) as dogs that are individually trained to do work or perform tasks for people with disabilities. Examples of such work or tasks include guiding people who are blind, alerting people who are deaf, pulling a wheelchair, assisting or protecting a person during a seizure, reminding a person with mental illness to take prescribed medications, calming a person with Post Traumatic Stress Disorder (PTSD) during an anxiety attack, or performing other duties. Service animals are working animals, not pets. The work or task a dog has been trained to provide must be directly related to the person's disability. Dogs whose sole function is to provide comfort or emotional support do not qualify as service animals under the ADA.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of service dog supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve service dog supplies to be provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit and related services provided on July 28, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit and related services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.    Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit and related services provided on July 28, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve seventeen (17) additional physical therapy (PT) visits.  You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not meet criteria.  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 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 the enrollee appears to have improved with therapy to the point that she has met all of her short-term goals and half of her long-term goals. Further skilled therapy with six additional visits have recently been approved. After completion of the now 24 approved visits, records indicate further utilization of the home exercise program would be most appropriate for 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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve seventeen (17) additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rest home visit provided on July 28, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  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 rest home visit provided on July 28, 2021 by an out-of-network (OON) provider.