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

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from May 30, 2019 to August 18, 2019.
You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticketdoes not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from May 30, 2019 to August 18, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe non-emergency transportation (A0110)You asked the Plan to pay forthe non-emergency transportation. You say that you live alone and do not have family to take you to medical appointments.The Plan denied your request. The Plan says this service is not a covered benefit.The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the non-emergency transportation have not been met.Therefore, we decided that the Plan does not have to pay forthe non-emergency transportation (A0110)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 19, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you had a visit for your prosthetics. You say that you don't feel responsible for $90.The Plan denied your request. The Plan says the claim was reprocessed to only apply the specialist visit copayment.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 Medicare-covered specialist visit. You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is a specialist. 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 nothave to waive the copayment forthe office visit provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe mental health services provided on September 5, 2019.You asked the Plan to pay forthe mental health services. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care. The plan states there are multiple in-network provider's available to you that can provide the care and treatment you need. 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 requirethe Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe mental health services provided on September 5, 2019.
Appeal type: Home Health
Decision: Favorable

We decided that the Planhasto pre-approvecontinued home health skilled nursing services beyond December 17, 2019.You asked the Planto pre-approvethe home health services. You say that the enrollee continues to require this care.The Plandenied your request. The Plansaysthatthe authorization request was reviewed and found that there is no longer any need for skilled home health services.The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing coverage of home care services. There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services at issue in this appeal.Therefore, we decided that the Planhas to pre-approvecontinued home health skilled nursing services beyond December 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided by "the provider" on June 16, 2019.You asked the Plan to pay forthe ambulance services. You say that the Plan should paythis claim.The Plan denied your request. The Plan says the enrollee requested the transport to another hospital.Medicare pays for ambulance services only whenthey are medically reasonable and necessary. The Plan follows the same rules. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forservices provided by "the provider" on June 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ankle foot orthoses provided on April 3, 2019.You asked the Plan to pay forthe ankle foot orthoses (L1971). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe ankle foot orthoses provided on April 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not haveto pay forthe wound care set, for negative pressure wound therapy electrical pump provided on September 11, 2019 by out of network provider.You asked the Plan to pay forthe wound care set. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request 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 has network providers available who can provide theitems/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 forthe wound care set, for negative pressure wound therapy electrical pump provided on September 11, 2019 by out of network provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after October 7, 2019.You asked the Plan to pre-approveSNF care. You say that the family has been very supportive but are unable to provide the type of support the enrollee needs to maintain her current level of health that has improved in the SNF setting.The Plan denied your request. The Plan says that the Medicare criteria for continued SNF level of coverage were not met.The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services.The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before October 7, 2019. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued.Therefore, we decided that the Plan has to pre-approvecontinued skilled nursing facility (SNF) services after October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on August 7, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you cannot afford this copayment. You say most of your doctor's are specialists. 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 thatyou must pay a $40 copayment for each Medicare-covered specialist visit. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's officevisits" 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 forthe specialist office visit provided on August 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on May 13, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes J7517 and J7505 are not supported.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 J7517 is mycophenolate mofetil, oral, 250 mg. The definition of code J7505 is muromonab-cd3, parenteral, 5 mg.We find that CPT codes J7517 and J7505 are not supported in the medical record. Specifically, there is no documentation for the dates of service in question. 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 forthe services rendered on May 13, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe compounded drug coded J7999 provided on December 5, 2018.You asked the Plan to pay forthe compounded drug. 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 supported by the documentation.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 J7999 is the compounded drug.We find that CPT code J7999 is not supported in the medical record. Specifically, the submitted medical records indicate that compounded drugs were administered and the appropriate code, J7999 has already been processed. It is inappropriate to bill multiple drug codes for given date of service. Based on this information, we decided that Medicare rules for coverage of the compounded drug have not been met.Therefore, we decided that the Plan does not have to pay forthe compounded drug coded J7999 provided on December 5, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on August 7, 2019.You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 Plandid not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decidedthat the Plan does not have to pay for a hospital outpatient clinic visit provided on August 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services provided on August 8, 2019.You asked the Plan to pay for the molecular pathology services.The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 did not pre-approve the servicesat 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 molecular pathology services provided onAugust 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveSunosi 150mg tablets.You asked the Planto pre-approvethe Sunosi tablets. You say that the enrollee would benefit from this medication.The Plandenied your request. The Plansaysthis oral medication is not covered by Medicare 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 Plandoes not haveto pre-approveSunosi 150mg tablets.Benefits forthe Sunosi tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe oxygen concentrator provided on August 1, 2019.You asked the Plan to pay forthe oxygen concentrator. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the facility is responsible to provide all services and pay vendors.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the oxygen concentrator was used in a SNF.Therefore, we decided that the Plan does not have to payforthe oxygen concentrator provided on August 1, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran emergency room visit provided on August 7, 2019.You asked the Plan to waive the copayment foremergency room visit. You say that you left without receiving service.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $90 copayment for emergency room visit. The record shows that you received emergency room services on this date of service, therefore the emergency care copayment applies to this claim.You have been asked to pay $90 copayment for emergency room visit. Emergency room visit falls within the Emergency 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 foran emergency room visit provided on August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided by "the provider" from August 9, 2019 to October 28, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate theDelivery Ticket.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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided by "the provider" from August 9, 2019 to October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.You asked the Plan to pre-approvethe compression stockings. You say that the authorization should be approved becauseyou did not know that the requirements were different now that he is covered under BCNA.The Plan denied your request. The Plan says gradient compression stockings A6530 are non-covered.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveRepatha SureClick injections.You asked the Planto pre-approvethe Repatha SureClick. You say that the enrollee requires this medication.The Plandenied your request. The Plansaysthis medication is for self-injection and is not covered by Medicare 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 Plandoes not haveto pre-approveRepatha SureClick injections.Benefits for the Repatha SureClickmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete maxillary denture and a complete mandibular denture.You asked the Plan to pre-approvethe complete maxillary and mandibular dentures. You say that you can hardly eat without any teeth in your mouth.The Plan denied your request. The Plan says these services are not a covered benefit on your plan.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 items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea complete maxillary denture and a complete mandibular denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe addition of a tooth to an existing denture (D5650) provided on August 14, 2019.You asked the Plan to pay forthe addition of a tooth to an existing denture. You say that you were advised by the Plan that the addition of a tooth to your denture would be covered 100%.The Plandenied your request. The Plan says only one denture adjustment is covered per calendar year.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 and denture repairs are a covered service, only one procedure is allowed per calendar year.Therefore, we decided that the Plan does not have to pay forthe addition of a tooth to an existing denture (D5650) provided on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pay forchiropractic services (CPT 98943) provided to the enrollee from July 24, 2019 to August 15, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis is 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 Plandoes not haveto pay forchiropractic services (CPT 98943) provided to the enrollee from July 24, 2019 to August 15, 2019.