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

We decided that the Plan does not have to pay for the skilled nursing services provided from October 11, 2019 to October 23, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF. The Plan also says that appropriate care could have been rendered/obtained at a lower level of care, or in the home.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from October 11, 2019 to October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 23, 2019.You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.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 medical records do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met.Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 9, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an
independent laboratory; however, the file shows that the specimen was obtained in an office setting and should
have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid provided on November 25, 2019.
You asked the Plan to pay for the hearing aid. You say that The Plan denied your request. The Plan says that prior authorization was not obtained for these services.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when received from a participating provider. We looked at the file and the Plan's rules. The file indicates the hearing aids were not received from a participating provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 10, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the service was medically necessary.The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain services.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 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 OON services. Therefore, we decided that the Plan does not have to pay forthe medical services provided on January 10, 2020 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 pneumatic compression device to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON items. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items can be provided by a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service requires 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 the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on January 24, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omeprazole 20mg tablets.You asked the Plan to pre-approve Omeprazole. You say that the Omeprazole is medically necessary.The Plan denied your request. The Plan says coverage for this type of drug is not available under the Part B Medical Benefit.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 Omeprazole 20mg tablets.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee from June 26, 2019
to June 27, 2019.
You asked the Plan to pay for the lab services. You say that the services should be paid separately as it was
performed separately. The Plan denied your request. The Plan says the services were billed with an invalid
modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We looked at the file and the rules. The professional/technical component does not apply for the services at
issue in this appeal. 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 lab services provided to the enrollee from June
26, 2019 to June 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.You asked the Plan to pre-approve the referral. You say that this is medically necessary.The Plan denied your request. The Plan says there is appropriate care available in-plan.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on December 10, 2019.
You asked the Plan to pay for the eyewear. You say that you are requesting reimbursement of services
rendered. The Plan denied your request. The Plan says you exhausted your benefit allowance.
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 exhausted your benefit allowance, because you used your $175
allowance for the eyewear. Your EOC states, there is a $175 vision allowance every two (2) years for routine
eyewear. Therefore, you are responsible for the remainder of the cost. Therefore, we decided that the Plan does
not have to pay for the eyewear purchased on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider 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 lab work provided on December 4, 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 the shower head (E1399).
You asked the Plan to pre-approve the shower head. You say that you are appealing the denial for the shower head because you really need one. The Plan denied your request. The Plan says this is not a covered benefit.
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 the shower head (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services provided on December 16, 2019 through December 30, 2019.
You asked the Plan to pay for the wound care services. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says when an enrollee elects hospice, Original Medicare takes effect on that day and all services after that date should be billed to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for wound care services provided on December 16, 2019 through December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on December 12, 2019.
You asked the Plan to waive the copayment for the medical eye exam. You say that you did not have a medical eye exam. The Plan denied your request. The Plan says that the copayment was 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 a $40 copayment for per visit for Medicare-covered exams to diagnose and treat diseases of the eye. You have been asked to pay a $40 copayment for the medical eye exam. The medical eye exam falls within the Medicare-covered exams to diagnose and treat diseases of the eye 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 the medical eye exam provided on December 12, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on July 3, 2019.
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee was under hospice election at the time of service. This claim should be submitted to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance transport provided to the enrollee on July 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care from December 1, 2017 through December 2, 2017.
You asked the Plan to pay for inpatient hospital care. You say that you should not be liable for the cost-share. The Plan denied your request. The Plan says 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 inpatient hospital care was not filed until November 15, 2019. 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 inpatient hospital care from December 1, 2017 through December 2, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on
December 6, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the
orthoses were medically necessary. The Plan denied your request. The Plan says the documentation submitted
did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes
cannot be verified.
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 medical records do not mention or support medical necessity for
the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthoses
(L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have
to pay for the knee orthoses and suspension sleeves provided on December 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S5501 and HCPCS S9502) provided to the enrollee from October 7, 2019 to October 12, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says these are invalid procedure codes for these 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.In this case, the CPT Code Manual definition of the denied codes is:HCPCS S5501:Home infusion therapy, catheter care / maintenance, complex (more than one lumen), includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem HCPCS S9502:Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately).We find that the denied codes are not supported in the medical record. Specifically, these codes have a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that these codes are not valid for Medicare purposes. 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 home infusion therapy services (HCPCS S5501 and HCPCS S9502) provided to the enrollee from October 7, 2019 to October 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foran L8619 (Cochlear implant, external speech processor and controller, integrated system, replacement) provided to the enrollee on October 18, 2019.You asked the Plan to pay for this equipment. You say that this claim should be paid.The Plan denied your request. The Plan says the records provided do not meet Medicare criteria for payment.The Plan says that the documentation submitted did not include proof of delivery to indicate the billed supply was delivered to the enrollee; therefore, the billed supply code cannot be verified. The Plan noted that multiple attempts were made to contact the provider for additional information.The Plan must follow Medicare rules. The rules state that durable medical equipment 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 physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain the required documentation. Therefore, we decided that the Plan does not have to pay foran L8619 (Cochlear implant, external speech processor and controller, integrated system, replacement) provided to the enrollee on October 18, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve14 additional physical therapy (PT) visits.You asked the Plan to pre-approve14 additional PT visits. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 14 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found for ankle and back pains, PT is generally accepted as specific and effective therapy. Goals include reducing pain, restoring function, and educating regarding a home exercise program (HEP) prior to transition towards a home program. In this case, there is no indication prior PT has served to provide sustained, significant improvement in pain and/or function and there are no indications that residual deficits could not be addressed via a home exercise program. Therefore, this request is deemed 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 14 additional PT visits have not been met.Therefore, we decided that the Plan does not have to pre-approve14 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 8, 2020 by an out of network (OON) provider.You asked the Plan to pay for the office visit. You say that you feel the plan should pay for these services received.The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.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 the office visit provided on January 8, 2020 by an out of network (OON) provider.