Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography and computed tomography (PET/CT) from the head to thighs.
You asked the Plan to pre-approve a PET/CT from the head to thighs. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that three fluorodeoxyglucose (FDG) positron emission tomography (PET) scans are nationally covered when used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer 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 a PET/CT from the head to thighs. Our reviewer says that the services are medically necessary. Our physician reviewer found a PET/CT is reasonable for you to assess the success or failure of chemotherapy following a Whipple procedure in 2019 for your pancreatic cancer. Reports of greater than 3 scans are not shown, and you have not yet finished with your therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET/CT from the head to thighs have been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography and computed tomography (PET/CT) from the head to thighs.
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 pay for the limited oral evaluation (D0140), bitewing x-ray (D0270), unspecified preventive service (D1999), periapical x-ray (D0230), comprehensive oral evaluation (D0150), prophylaxis (D1110), and complete series x-ray (D0210) provided from September 19, 2020, to March 12, 2021.
You asked the Plan to pay for the dental services. You say that your regular dentist is not seeing patients due to the coronavirus. You say that you this caused you to have to go out of network. You say that before the work was started, you asked the office to confirm they accepted his insurance. You also say you were advised they did only to find out later they do not. The Plan denied your request. The Plan says the dentist in this case is out of network. The Plan also says that dental care rendered by a provider that is not part of our supplemental dental network 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. Though the Plan offers a dental benefit in excess of Medicare coverage, dental services you receive out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), bitewing x-ray (D0270), unspecified preventive service (D1999), periapical x-ray (D0230), comprehensive oral evaluation (D0150), prophylaxis (D1110), and complete series x-ray (D0210) provided from September 19, 2020, to March 12, 2021
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on October 8, 2021.
You asked the Plan to pay for the outpatient services. You say that the enrollee's plan has taken back their payment in error. You say that the enrollee was discharged to hospice on the date of service in this case. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the outpatient services provided on October 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 skilled nursing visits (G0299), 10 physical therapy visits (G0151), 10 occupational visits (G0152), 2 home health aide visits (G0156), and 2 medical social worker visits (G0155).
You asked the Plan to pre-approve the home health services. You say that the services are medically necessary. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that home health services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The reviewer found that based on the medical records provided there is no documentation that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration. Records do not document a change in condition that would necessitate skilled therapy services. The reviewer also found that since there is no need for skilled nursing or therapy services that is documented, no home health aide services are covered. 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 home health services have not been met. Specifically, the file shows that the enrollee does not have any skilled nursing or skilled therapy needs. Therefore, we decided that the Plan does not have to pre-approve 10 skilled nursing visits (G0299), 10 physical therapy visits (G0151), 10 occupational visits (G0152), 2 home health aide visits (G0156), and 2 medical social worker visits (G0155).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the ambulance response and treatment, no transport (A0998) provided on August 3, 2020.
You asked the Plan to reimburse you for the ambulance service. You say that the enrollee fell and was injured. You say that the emergency medical services (EMS) personnel determined treatment at the scene was sufficient and transport was not necessary. You say that you paid the bill for this service as to not get sent to collections. You also say that you feel you should not be responsible for this bill and therefore should be reimbursed. The Plan denied your request. The Plan says treatment provided by an ambulance without transportation is not covered by your plan benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
The ambulance company did not provide transport services on August 3, 2020. 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 reimburse you for the ambulance response and treatment, no transport (A0998) provided on August 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral surgery services provided from May 21, 2021, to May 28, 2021, by a provider who has opted-out of Medicare.
You asked the Plan to pay for the oral surgery services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says payment is not eligible for a provider who has opted-out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the oral
surgery services provided from May 21, 2021, to May 28, 2021, by a provider who has opted-out of Medicare
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Minuteman interspinous device rendered on May 4, 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 the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. The Minuteman spacer is considered experimental in nature, as more research is needed to show safety and efficacy. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the Minuteman interspinous device rendered on May 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on September 17, 2021 and discharged to SNF on September 22, 2021. She is ambulating more than 100 feet and tending to activities of daily living with minimal supervision. She has no skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis as the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the $45 copayment for the specialist services on May 14,
2021.
You asked the Plan to pay for the copayment. You say that the visit was the same as another, but the care was
the same. The Plan denied your request. The Plan says the care was not the same, so the 45$ copayment was
appropriate.
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 $45
copayment for practitioner services.
You have been asked to pay $45 copayment for the copayment. the copayment falls within the practitioner
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 pay for the $45 copayment for the specialist services
on May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for tissue pathology (88305) provided on March 2, 2021.
You asked the Plan to pay for the tissue pathology. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare criteria for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 88305 is not supported in the record. Specifically, the record indicates that the member was inpatient on the billed date of service. Payment for the technical component of this laboratory service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage of the tissue pathology have not been met. Therefore, we decided that the Plan does not have to pay for tissue pathology (88305) provided on March 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided on November 23, 2020 to
January 20, 2021 by an out-of-network (OON) provider.
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 the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. 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 home health services provided on November
23, 2020 to January 20, 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 ophthalmological services (99336, 92020, 92202)
provided on April 12, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the ophthalmological services. You say that you would like this claim
reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not
obtained for these services rendered by an OON 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 the ophthalmological services (99336, 92020, 92202) provided on April 12, 2021, by an out-of-network (OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency ambulance transportation (A0428-HN), and ground mileage (A0425-HN) provided on April 13, 2021.
You asked the Plan to pay for the ambulance services. You say that the ambulance services were medically reasonable and necessary. The Plan denied your request. The Plan says the ambulance services were not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ambulance services. Our reviewer says that the ambulance services are not medically necessary. Our physician reviewer found provided documentation indicates the enrollee was transported to a care facility and was medically stable. The reviewer found that the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on April 13, 2021.
The reviewer also found that the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on April 13, 2021. The documentation did not support that the ambulance transport on April 13,2021 was medically reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Specifically, the file does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee. Therefore, we decided that the Plan does not have to pay for non-emergency ambulance transportation (A0428-HN), and ground mileage (A0425-HN) provided on April 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a breast x-ray provided on February 8, 2021.
You asked the Plan to waive the deductible for the x-ray. You say that the Plan paid for this x-ray last year and it was billed the same way. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 $395 deductible which applies to the x-ray. The x-ray you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $395 deductible which applies to x-rays. This cost sharing is a contractual obligation that had not been met at the time the x-ray was received on February 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a breast x-ray provided on February 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on November 18, 2020.
You asked the Plan to pay for the evaluation and management service. You say that the enrollee was not enrolled in hospice on the date of service. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on November 5, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent
hospital care (99233) provided on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on May 4, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you would like this copayment waived. The Plan denied your request. The Plan says you have not met the maximum out of pocket benefit.
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 $50 copayment for physician specialist services. You have been asked to pay a $50 copayment for the office visit. This service falls within the physician specialist services benefit category. You had not yet met your maximum out of pocket benefit at the time of this service. 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 office visit (99214) provided on May 4, 2021.