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

We decided that the Plan does not have to pay for the Acetaminophen tablets, Celecoxib capsules, Tamsulosin capsule, and Gabapentin capsule provided on November 7, 2019.You asked the Plan to pay for the Acetaminophen, Celecoxib, Tamsulosin, and Gabapentin. You say that you would like to know if these charges can be billed to Medicare Part D.The Plan denied your request. The Plan says these drugs are classified as self-administered drugs, of which none are covered under 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 Plan does not have to pay forthe Acetaminophen tablets, Celecoxib capsules, Tamsulosin capsule, and Gabapentin capsule provided on November 7, 2019.Benefits for the Acetaminophen, Celecoxib, Tamsulosin, and Gabapentin may 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 for lumbar sacral orthosis (L0650) provided on December 17, 2019.You asked the Plan to pay for the lumbar sacralorthosis. You say that you would like reconsideration because the lumbar sacral orthosis is medically necessary.The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services to confirm Medicare coverage has been 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 for lumbar sacral orthosis (L0650) provided on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the disposable briefs provided from October 1, 2019 through December 28, 2019.
You asked the Plan to provide additional reimbursement for the disposable briefs. You say that The Plan denied your request. The Plan says that you have exhausted your quarterly reimbursement amount.
The Plan must follow Medicare rules. However, the Plan offers an OTC benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to a $150 allowance for eligible OTC items every quarter. We looked at the file and Medicare rules. The file shows that the plan has approved the maximum quarterly benefit of $150 for the requested services. There is no provision in the contract which would require the plan to approve more than this amount. Therefore, we decided that the Plan does not have to provide additional reimbursement for the disposable briefs provided from October 1, 2019 through December 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental consultation provided on September 9, 2019.You asked the Plan to pay forthe dental consultation. The Plan denied your request. The Plan says that you are responsible for the full cost if the provider is not eligible to participate in Medicare.The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who isnot enrolled in the Medicare Program.These services were not provided by a provider who is enrolled in the Medicare program.Therefore, we decided that the Plan does not have to pay forthe dental consultation provided on September 9, 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-approveIRF care. You say that the records provided support the need for IRF care and support that the criteria for coverage have been met.The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria that requires a high level of physician supervision in combination with therapy services in an inpatient setting.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 the enrollee was medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician. There is no evidence of a need for acute rehabilitation nursing care. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. The enrollee's rehabilitation needs can be met at a lower intensity setting, such as a skilled nursing facility.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
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 the records provided support the need for IRF care. The Plan denied your request. The Plan says there are no skilled nursing needs or skilled therapy needs. The Plan says that the enrollee is medically stable and does not need to be seen by a doctor that specializes in rehab three times per week. The Plan says that the enrollee does not need specialized training, staff, or equipment of an IRF. The Plan says that the enrollee does not have complex medical needs and does not meet the criteria for coverage of IRF care.
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 the enrollee was medically stable with no evidence of need for supervision by physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care. The enrollee may benefit from further physical therapy and an occupational therapist, but does not require an intensive therapy program. An IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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 a hospital bed (E0256, 99199, S9999) provided by a provider who does not participate in Medicare on November 12, 2019. You asked the Plan to pay for a hospital bed. You say that this item had been approved but you needed it sooner than the approved order could be delivered. The Plan denied your request. The Plan says the provider of this item does not participate in Medicare. The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. The provider you purchased the hospital bed at issue from does not participate in Medicare. Based on this information, we decided that Medicare rules for coverage of a hospital bed have not been met. Therefore, we decided that the Plan does not have to pay for a hospital bed (E0256, 99199, S9999) provided by a provider who does not participate in Medicare on November 12, 2019.
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 October 11, 2019 to October 30, 2019. You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment is not allowed for this claim because the FIPS code is missing or is invalid. 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 submitted claim does not include the required FIPS code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 11, 2019 to October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement of nail(s) provided on December 18, 2019.
You asked the Plan to pay for the debridement of nail(s). The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
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
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 debridement of nail(s) provided on December 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided on June 11, 2019.
You asked the Plan to pay for the self-administered drugs. You say that you would like reconsideration because
you were given these drugs while in the hospital for your condition. The Plan denied your request. The Plan
says these drugs are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pay for self-administered drugs provided
on June 11, 2019.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Your complaint about being given incorrect information is not a valid appeal for medical coverage. This part of
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 31, 2019. You asked the Plan to pay for the laboratory services. You say that the ordering physician indicated that the enrollee met the coverage criteria for the Medicare policy. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. 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 October 19, 2019. 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 laboratory services provided on October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bitewing x-rays (D0274) and periapical x-rays ( D0230 and D0220) provided on December 5, 2019. You asked the Plan to pay for the dental x-rays. You say that you would like reconsideration because you have dental benefits that should cover x-rays. The Plan denied your request. The Plan says these x-rays are not a covered benefit under your basic dental 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 pay for a bitewing x-rays (D0274) and periapical x-rays ( D0230 and D0220) provided on December 5, 2019.
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
September 2, 2019 to September 25, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says there are billing issues with the claim
submission due to an invalid procedure code and/or type of bill code.
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, this claim
has been submitted with an invalid type of bill code for home health services. Therefore, we decided that the
Plan does not have to pay for the home health services provided to the enrollee from September 2, 2019 to
September 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (TOF - testing to monitor the depth of muscle relaxation during surgery - coded as 95999 - Unlisted neurological or neuromuscular diagnostic procedure) provided on February 8, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The record sent by your provider indicates that you underwent a sacral fusion requiring neurophysiology monitoring. Other neuromonitoring services have been approved for payment by the Plan. Medicare guidelines say that this item or service is considered a bundled procedure as the cost is included in the cost of the primary procedure. Under Medicare guidelines, your request is not a covered benefit because Medicare does not make separate payment for this service. Therefore, we decided that the Plan does not have to pay for train of four testing (TOF - testing to monitor the depth of muscle relaxation during surgery - coded as 95999 - Unlisted neurological or neuromuscular diagnostic procedure) provided on February 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 33418 (transcatheter mitral valve repair) provided on October 30, 2019.You asked the Plan to pay for CPT code 33418. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says NCT02033811 is an observational study listed only for a site in Europe. The clinical trial number 02033811 is not listed on the Medicare web site for the Transcatheter Mitral Valve Repair (TMVR) under Coverage with Evidence Development. The Plan states they will accept a corrected claim with a valid clinical trial number.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. Medicare says Plans shall pay TMVR for MR claim lines billed with CPT code 33418 in a clinical trial only when billed with an 8-digit national clinical trial number. The file shows the claim was submitted with an invalid national clinical trial number for the TMVR procedure to be considered for payment.Therefore, we decided that the Plan does not have to pay for CPT code 33418 (transcatheter mitral valve repair) provided on October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 30, 2019.
You asked the Plan to pay for the laboratory 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 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. We find that CPT codes 82136, 82310, 82495, 82525, 82725, 82978, 83735, 83785, 84630,82180, 82652, 84252, 84425, 84446, 84590, 84597, and 84999 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order and results for the billed date of service. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient behavioral health services for the enrollee.
You asked the Plan to pre-approve continued services. You say that the enrollee has mood dysregulation and behavioral disturbances that is interfering with social and interpersonal functioning. The Plan denied your request. The Plan says inpatient services were no longer medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued services. Our physician reviewer found that active treatment was not taking place. It did not appear that the services were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. This enrollee was treated under an individualized treatment plan, and was supervised and evaluated by a physician. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 24, 2020 forward. The services can be treated in a lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient behavioral health services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided to you by an out-of-network provider on January 14, 2020. You asked the Plan to pay for the dental services. You say that you did not know the provider left the network. The Plan denied your request. The Plan says out-of-network services are not covered. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit when provider by a non-participating provider. The requested provider is an out-of-network provider under your plan. Therefore, we decided that the Plan does not have to pay for the dental services provided to you by an out-of-network provider on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) provided from October 15, 2019.
You asked the Plan to pay for critical care. You say that this was billed appropriately. The Plan denied your request. The Plan says this code is not supported in the records.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent on this service is not documented in the records. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) provided from October 15, 2019.