Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 2, 2019 to May 31, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the facility claim was billed with an incorrect type of bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from May 2, 2019 to May 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on January 22, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on January 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bathtub lift purchased on July 19, 2019.
You asked the Plan to pay for the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says this is a personal comfort and convenience item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for bathtub lift purchased on July 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Foresee Home AMD Monitoring system (CPT 0397T).
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says the requested code is statutorily not covered.
The Plan must follow Medicare rules. The rules say that CPT 0397T is not a covered code. The requested system is coded with CPT 0379T. Based on this information, we decided that Medicare rules for coverage of the system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Foresee Home AMD Monitoring system (CPT 0397T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided to the enrollee on October 14, 2019.
You asked the Plan to pay for the services provided. You say that the report shows the time spent for the moderate sedation. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code that describes the services performed. In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not show the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided to the enrollee on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography studies coded 51785 provided on August 7, 2019.
You asked the Plan to pay for the needle electromyography studies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that procedure code 51785 is only covered when billed with specific diagnosis codes listed. We looked at the file and Medicare rules. Code 51785 was billed with diagnosis code M51.36 (other intervertebral disc degeneration, lumbar region.) Diagnosis code M51.36 is not listed as a covered diagnosis code for this procedure code. Based on this information, we decided that Medicare rules for coverage of the needle electromyography studies have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography studies coded 51785 provided on August 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglass you received on March 26, 2019.
You asked the Plan to pay for the eyeglasses. You say that there is no indication that you must go to a network provider. The Plan denied your request. The Plan says the eyeglasses were purchased outside of the plan's network.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. You received glasses from a non-plan facility. Your plan only covers eyeglasses from a plan optical facility. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglass you received on March 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image (D0230) and unspecified endodontic procedure, by report (D3999) provided on November 20, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that your insurance accepted to covered the services. The Plan denied your request. The Plan says the services are not approved for coverage.
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. We reviewed your records and they show that you saw the dentist and received multiple dental x-rays, a root canal and a second endodontic procedure, in addition to other dental services. The record sent by your provider indicates that 2 sets of intraoral x-rays were performed at your visit and two endodontic procedures. Your request is not a covered benefit because your records show that you had 2 sets of intraoral x-rays and 2 endodontic procedures and one of each has already been approved for payment by the Plan. We are unable to approve your request for payment for an additional set of intraoral x-rays and an additional endodontic procedure. Therefore, we decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image (D0230) and unspecified endodontic procedure, by report (D3999) provided on November 20, 2019 by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for care management provided on January 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for care management. You say that since the member is in a living facility , the doctor is not responsible to get authorization. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring facility is also out-of-network.
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 has network providers available who can provide 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 care management provided on January 30, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system.
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF system is not covered by Medicare or the Plan in this case.
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. Medicare says there appears to be limitations with lack of long-term clinical outcomes, specific study limitations, and need for additional studies for implantation of a CardioMEMS HF device. At this time, Medicare considers this device investigational and considers this non-covered unless in an approved clinical trial. Based on this information, we decided that Medicare rules for coverage of a CardioMEMS HF system have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto (J8499) for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this plan only has Part B coverage.
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 Xarelto (J8499) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from December 27, 2019 to December 31, 2019.
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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, the CPT Code Manual definition of code S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not supported in the medical record. Specifically, code S9328 has a status code of "I." A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from December 27, 2019 to December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myoeletric orthotic device for the enrollee.
You asked the Plan to pre-approve the requested device. You say that the device will restore the enrollee's lost arm functions. The Plan denied your request. The Plan says there is no medical proof showing the device will help 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 pre-approve the requested device. Our physician reviewer found that the enrollee is post a C3 spinal cord injury. He is unable to bear weight throughout the arms and strength is between 1-3 out of 5. He has difficulty performing activities of daily living due to his incomplete tetraplegia. Records are not convincing that this device will provide meaningful improvements in function including mobility related activities of daily living performance, above a standard body-powered device. As such, this request is not 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 the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve myoeletric orthotic device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve So Clean CPAP cleaning machine.
You asked the Plan to pre-approve the So Clean CPAP cleaning machine. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says this item is considered hygienic and not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve So Clean CPAP cleaning machine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the wig provided on September 5, 2019.
You asked the Plan to reimburse you for the wig. You say that the wig was prescribed due to hair loss from chemotherapy. The Plan denied your request. The Plan says Medicare does not deem wigs as medically necessary. You plan does not offer an additional supplemental benefit for wigs.
The Plan must follow Medicare rules. Medicare rules say that Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician.
We looked at the file and Medicare rules. In this case, although the wig may be appropriate for you, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is non-covered by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the wig provided on September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan denied your request. The Plan says these supplies are not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve adult incontinence supplies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on August 23, 2019.
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges. 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 $50 copayment for outpatient hospital services. You have been asked to pay a $50 copayment for an X-ray. An X-ray falls within the outpatient hospital 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 an X-ray provided on August 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on November 8, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says records were not provided for the date of service in question.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the non-contract provider for the date of services in question. Without records, it cannot be determined that Medicare coverage criteria have been met. 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 services provided on November 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 20, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that your services are an extension of the initial visit.
The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate
network providers were found.
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 referring provider is no a
network provider with the Plan. The Plan has network providers available who can provide 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 medical services
provided on September 20, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist visit and X-rays and does not have to waive the coinsurance for a Medicare Part B drug on January 14, 2020.
You asked the Plan to waive the copayments for a specialist visit and X-rays and to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the charges. 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 $50 copayment for each specialist visit. Your contract with the Plan also clearly says that you must pay a $60 copayment for X-rays. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a specialist visit on January 14, 2020. Therefore, you are responsible to pay the $50 copayment. You received X-rays on January 14, 2020. Therefore, you are responsible to pay the $60 copayment. You received a Medicare Part b drug on January 14, 2020. The allowed amount is $1.63 and 20% of that is $.33. The total amount you owe is: $110.33.
You have been asked to pay the total amount you owe is $110.33 for specialist visits, X-rays and a Medicare Part B drug. Specialist visits fall within the physician/practitioner services, including doctor's office visits benefit category. X-rays fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 copayments for a specialist visit and X-rays and does not have to waive the coinsurance for a Medicare Part B drug on January 14, 2020.
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 SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for SNF services are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF services. Our physician reviewer found based on the medical records, you do not require daily skilled nursing services. You do not have a tracheostomy tube, new enteral feedings, complex wound care or any other SNF level skilled nursing need. The Foley condition is chronic and does not require a SNF admission for care. The current functional status does not support that you require daily skilled therapy services. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" at a SNF level of care. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.