Persius/hicric huggingface dataset:
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria for IRF care has not been met.
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 there is no reason to think that an intensive rehabilitation therapy program would
significantly impact your condition differently compared with therapy provided at a less intense level. Your
care can be appropriately provided at a skilled nursing facility (SNF) level.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe blood pressure monitor provided on April 25, 2019.You asked the Plan to pay forthe blood pressure monitor. You say that the Plan should pay this claim.The Plan denied your request. The Plan says ambulatory blood pressure monitoring must be performed for at least 24 hours and services provided during transport are not paid separately.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 A4670 is Automatic blood pressure monitor.Blood pressure monitoring is included in the Medicare fee schedule for ambulance services. Based on this information, we decided that Medicare rules for coverage of the blood pressure monitor have not been met.Therefore, we decided that the Plan does not have to pay forthe blood pressure monitoringprovided on April 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical pathology services provided on August 6, 2019.You asked the Plan to pay forthe surgical pathology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 Plandid not pre-approvethe 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 forsurgical pathology services provided on August 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you attended a festival when you suddenly became ill. You say that you felt dizzy and faint and someone called for an ambulance. You were taken into the ambulance where they tested and evaluated your vitals while giving you water and ice. They believed that you were having a heat related incident due to the high temperatures. You say you began to feel substantially better and declined transportation because the symptoms were no longer present. You say that you were unaware that by not being transported you would be responsible for the entire amount which is a financial hardship for you. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 13, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 25, 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 the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS code G0481 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on March 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 18, 2019.You asked the Plan to waive the copayment for the office visit. You say that you should not be charged a $5 copayment for a preventive exam.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 that you must pay a $5 copayment for PCP office visits. You have been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows the reason for the office visit was due to a dermatology problem.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 office visit provided on October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on October 22, 2019.You asked the Plan to pay for the dental service. You say that you wanted to keep your appointment. You say that you thought you were there for a cleaning but you were scheduled for periodontics. You also say that you were not aware periodontics was not contracted because the provider was the one that scheduled the visit.The Plan denied your request. The Plan says dental services that you receive out of network are not covered. The Plan also says that the provider in this case is not a network provider. 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, dental services are not covered when you receive them out of network.Therefore, we decided that the Plan does not have to pay for the consultation (D9310) provided on October 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the phenylephrine/ketorolac injections
provided on July 15, 2019 and August 5, 2019.
You asked the Plan to waive the coinsurance for the injections. You say that this should be included in the
surgical services copayment. The Plan denied your request. The Plan says that the coinsurance applied
correctly.
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 20%
coinsurance for Medicare Part B Prescription Drugs.
You have been asked to pay a 20% coinsurance for the injections. The injections fall 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 coinsurance for the
phenylephrine/ketorolac injections provided on July 15, 2019 and August 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 22, 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 Current Procedural Terminology (CPT) code 80307 remains not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on August 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that the orthotics are necessary to maintain the functional results achieved with the medical or surgical treatment of the enrollee's foot condition.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on November 14, 2019.You asked the Plan to pay forthe periodic oral evaluation and prophylaxis. You say that you originally had an appointment scheduled for December 4, 2019 but the dentist had an earlier cancellation in November, and you did not think about the time between the visits.The Plan denied your request. The Plan says these procedures are covered once every 6 months.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, oral exams and cleanings are each limited to 1 every 6 months. The record shows that you received a periodic oral evaluation and prophylaxis on May 22, 2019 and your oral exams and cleanings benefit were then exhausted for the 6 month period.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on November 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 4, 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 the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We find that HCPCS code G0481 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on April 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on April 20, 2019 and billed under codes 80307 and G0483.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. The Plan says that Current Procedural Terminology (CPT) codes 80307 and G0483 remain not supported. The documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore, the billed code cannot be verified. The Plan notes that multiple attempts were made to obtain additional information from the provider.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order must be signed appropriately, and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on April 20, 2019 and billed under codes 80307 and G0483.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services provided to the enrollee on September 11, 2019 and billed under code J9035.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS Code) J9035 remains not supported. Healthcare Common Procedure Coding System (HCPCS) code represents injection, bevacizumab, 10 mg. The submitted documentation indicated that an Avastin injection for off label ophthalmic use was administered. There is a more appropriate HCPCS code J7999, as required by the Local Coverage Article A53008. The Medicare rules say that when billing for bevacizumab (Avastin) for off label ophthalmic use which is Q, code J7999 should be used. Therefore, the billed code and unit cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules say code J7999 is the appropriate code to be used for an Avastin injection. Medicare rules for coverage of this service as billed have not been met. Therefore, we decided that the Plan does not have to pay for injection services provided to the enrollee on September 11, 2019 and billed under code J9035.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 15, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physician's services provided on July 15, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room provided on October 21, 2019.You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment because they did not find any issues while you were at the emergency room. 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 that you must pay a $90 copayment for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you received services during your emergency room stay.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 emergency room provided by on October 21, 2019.Your complaint that the hospital does not care 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Bacitracin ointment and Oxymetazolinesolution provided on September 30, 2019.You asked the Plan to pay forthese drugs. The Plan denied your request. The Plan says that self-administered drugs are not covered.The Plan must follow Medicare rules. The rules say that Medicare Part Bgenerally 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 Bacitracin ointment and Oxymetazoline solution provided on September 30, 2019.Benefits for these drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 2,
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 the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be
covered.
The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly tests were to be performed. 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 drug testing
services provided to the enrollee on April 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea heavy duty extra wide hospital bed (E0303).You asked the Plan to pre-approvethe heavy duty extra wide hospital bed. You say that your mattress is worn out and not comfortable, and you are too big for your bed.The Plan denied your request. The Plan says you do not meet Medicare coverage criteria for the item requested.The Plan must follow Medicare rules. The rules say that aheavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds.We looked at the fileand Medicare rules. In this instance, the documentation does not show that you weigh between 350 pounds and 600 pounds. Based on this information, we decided that Medicare rules for coverage of the heavy duty extra wide hospital bed have not been met.Therefore,we decided that the Plan does not have to pre-approvea heavy duty extra wide hospital bed (E0303).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 24, 2019 by an out of network (OON) provider.You asked the Plan to pay for HyperbaricOxygen Therapy supervision (99183). You say that you would like reconsideration as these services are a covered benefit.The Plan denied your request. The Plan says utilization of network providers when available and authorization for certain services are required.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 forthe medical services provided on September 24, 2019 by an out of network (OON) provider
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from March 12, 2018 to March 16, 2018.You asked the Plan to pay for this claim as billed. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the claims are being submitted with inappropriate home health data to process and pay claims. Per the Medicare guidelines, Home Health Final claims are required to have the correct bill type 329. It was also determined the claim was billed with"S"code, and per Medicare home health services are required to have the appropriate "G"codes and "Q"code to process and pay claims. Medicare billing criteria were not met. 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 claim was submitted with inappropriate codes preventing payment. Based on this information, we decided that Medicare rules for coverage of this claim as billed have not been met.Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from March 12, 2018 to March 16, 2018.