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

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960) and the wrist hand orthosis (L3916) provided on December 28, 2019.
You asked the Plan to pay for these items. You say that the orthoses are medically necessary for the enrollee. The Plan denied your request. The Plan says the documentation indicates that the items at issue are not necessary for the treatment of the enrollee's condition.
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 items. Our reviewer says that the items at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaints were shoulder pain and wrist pain. A physical examination of the shoulder and wrist would reasonably be required to adequately assess whether the shoulder/arm orthosis and the wrist/hand orthosis were medically necessary for an enrollee. The documentation does not support that the orthoses provided were medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible physical examination of the shoulder and wrist. 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 items have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960) and the wrist hand orthosis (L3916) provided on December 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0150) provided to you on October 19, 2020.
You asked the Plan to pay for the oral exam. The Plan denied your request. The Plan says this is not a covered benefit.
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 services are not among those covered under this benefit. The Plan covers only those dental codes listed in the Evidence of Coverage. Dental code D0150 is not listed, and therefore is not covered. Therefore, we decided that the Plan does not have to pay for the oral exam (D0150) provided to you on October 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira.

You asked the Plan to pre-approve Humira. You say that the medication has been effective for the enrollee's diagnosis. The Plan denied your request. The Plan says the medication does not fall under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Humira.

Benefits for Humira may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90792) provided on February 7, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not payable as the claim was submitted untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for this service was not filed until September 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90792) provided on February 7, 2019.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 above. 

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 you had acute respiratory failure and is status post extubation. Congestive heart failure was decompensated and now compensated. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program. Your care needs can be met 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered chiropractic services and supplies on December 4, 2020.

You asked the Plan to pay for the office visit, physical therapy technique, hot or cold pack application, electrical stimulation, and supplies and materials. You say that you called the Plan and were misinformed about your benefits. The Plan denied your request. The Plan says your phone call of December 7, 2020 was reviewed and you were advised chiropractic services are limited to manual manipulation of the spine to correct subluxation.

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. 

The record shows there was no contact with the Plan prior to your first visit to verify the benefit. Therefore, we decided that the Plan does not have to pay for the non-covered chiropractic services and supplies on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior authorization was not obtained.
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 physician services provided on October 20, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on September 29, 2020.

You asked the Plan to waive the copayment for an outpatient surgery. You say that you were not charged this much last time for a similar procedure. 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 $500 copayment for outpatient surgery. 

You have been asked to pay $304.97 which is less than your copayment amount of $500 for an outpatient surgery. The injection that was provided is considered an outpatient surgery service; therefore, the correct copayment has been applied. An outpatient surgery falls within the outpatient surgery 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 an outpatient surgery provided by a participating provider on September 29, 2020.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 above. 

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 you required moderate assistance for bed mobility. You required minimal assistance to stand up and sit down and walk 70 feet using a two wheeled walker. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program. Your care needs can be met 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the group 1 heavy duty power operated vehicle purchased
July 15, 2020.
You asked the Plan to pay for the group 1 heavy duty power operated vehicle. You say that your provider
approved the power operated vehicle as medically necessary. The Plan denied your request. The Plan says there
was no evidence of a standard written order for the item you purchase with an examination by your provider.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid physician order. In this case, there does not appear to be a physician order
prior to the purchase of the power operated vehicle. Although there is a letter from your provider, this is dated
after the equipment was already purchased. The record shows that the Plan made several attempts to obtain the
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the
group 1 heavy duty power operated vehicle purchased July 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99232) coagulation function screening test with interpretation and report (85390) initial hospital inpatient care (99223) blood count; complete (85025) provided November 17, 2019 to November 22, 2019.

You asked the Plan to pay for the inpatient services. You say that you paid the ship's medical emergency charges, hotel stay charges and other resulting personal minor expenses incurred. You have not been compensated for your out of pocket's paid. The Plan denied your request. The Plan says proof of payment is needed for claims reconsideration. These claims cannot be reprocessed for payment until proof of payment is received.

The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says if you have an urgent need for care while outside of the U.S. and its territories, you will be responsible to pay for the services rendered upfront. You must submit proof of payment to the Plan for reimbursement.

You have been asked to pay $20,356 for the inpatient services. The inpatient services fall within the Urgently needed 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 subsequent hospital care (99232) coagulation function screening test with interpretation and report (85390) initial hospital inpatient care (99223) blood count; complete (85025) provided November 17, 2019 to November 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on April 15, 2019.

You asked the Plan to pay for the prophylaxis. You say that you were unaware you had coverage under Medicare. The Plan denied your request. The Plan says the claim in question was not received within the 12-month filing deadline and will not be covered under Original Medicare or the 2019 Evidence of Coverage.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the prophylaxis was not filed until October 29, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on April 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stealth simple solutions adapter plate, a rear accessory bar, a gatlin midline mount and a track mounted clamp.

You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan denied your request. The Plan says that these items cannot be separately billed.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that you have the joystick (E2312) and custom fabricated wheelchair back cushion (E2617). The joystick (E2312) and custom fabricated wheelchair back cushion (E2617) serve the same purpose as these items. Therefore, we decided that the Plan does not have to pre-approve a stealth simple solutions adapter plate, a rear accessory bar, a gatlin midline mount and a track mounted clamp.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the acupuncture treatment (97810, 97811) and the massage therapy (97124) provided from May 4, 2020, through October 8, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the documentation does not indicate the medical necessity of the services provided.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were referred for these services by a contract provider. The file does not show that the Plan provided notice that these services would not be covered. Under Medicare rules, this means these services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the acupuncture treatment (97810, 97811) and the massage therapy (97124) provided from May 4, 2020, through October 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medial branch radiofrequency thermocoagulation
provided on July 14, 2020.

You asked the Plan to pay for destruction by neurolytic agent (64635, 64636). You say that the Plan should pay
this claim. The Plan denied your request. The Plan says the records do not show the enrollee had 80% relief
with facet injections prior to this procedure.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file and Medicare rules. the documentation submitted does not show that previous facet joint
injections were at least 80% effective for pain control. Based on this information, we decided that Medicare
rules for coverage of destruction by neurolytic agent (64635, 64636) have not been met. Therefore, we decided
that the Plan does not have to pay for the medial branch radiofrequency thermocoagulation provided on July
14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on March 7,
2020.
You asked the Plan to waive the copayment for ambulance services. You say that you feel that if the facility
would have been better the enrollee would not have required the ambulance. The Plan denied your request. The
Plan says the claims were processed correctly, and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $265 copayment for ambulance services.
The enrollee has been asked to pay a $265 copayment for ambulance services. Ambulance services fall within
the ambulance services 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 copayment for
ambulance services provided on March 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the custodial care provided to the enrollee from May 1, 2020, to March 31, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says custodial care is not covered.

The Plan must follow Medicare rules. Medicare rules say that custodial care is excluded from coverage. 

We looked at the file and Medicare rules. The records show that the enrollee received custodial care at an assisted living facility from March 1, 2020, to March 31, 2020. Custodial care is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the custodial care provided to the enrollee from May 1, 2020, to March 31, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric evaluation (90792) provided on April 2, 2019.

You asked the Plan to pay for a psychiatric evaluation. You say that you did not receive the necessary information to file this claim timely. The Plan denied your request. The Plan says this claim was filed more than a year after the date of service.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for a psychiatric evaluation was not filed until August 26, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a psychiatric evaluation (90792) provided on April 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Annual Routine Physical provided December 7, 2020.
You asked the Plan to pay for the Annual Routine Physical. You say that you were not aware you had already used your benefit for the year. The Plan denied your request. The Plan says your annual physical benefit has already been used.
The Plan must follow Medicare rules. The rules say that routine physical checkups are not covered by Medicare. Based on review of the file, an annual physical was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the Annual Routine Physical provided December 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from September 26, 2019, to September 30, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not owe a copayment for the first 20 days of a skilled nursing facility stay. 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 $295 copayment for days 1-6 for inpatient hospital care. You had an inpatient hospital stay from September 26, 2019, to September 30, 2019. This is considered a new inpatient hospital stay. Therefore, you are responsible to pay $940, which is less than the total copayment amount. You have been asked to pay $940 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided from September 26, 2019, to September 30, 2019.