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

We decided that the Plan does not have to pay for practitioner services on June 25, 2019.
You asked the Plan to pay for practitioner services. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee was enrolled in Hospice benefits on the date of service.
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 practitioner services on June 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve K3 advanced knee and foot prosthesis (L5986, L5987 and L5814).
You asked the Plan to pre-approve the K3 prosthesis. You say that the member can ambulate at the K3 level and the requested prosthesis is medically necessary. The Plan denied your request. The Plan says the notes do not show why the requested advanced knee and foot are needed and the records do not indicate that the member can ambulate at a K3 level.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the K3 prosthesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has not been a K3 ambulator for several years. There is not a documented medical reason why the K3 components are medically necessary. The requested prosthetic components exceed the patient's medical need. 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 K3 prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve K3 advanced knee and foot prosthesis (L5986, L5987 and L5814).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) and shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on August 30, 2019.
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
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) and shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on August 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for acute inpatient rehabilitation care from
January 21, 2019 through February 6, 2019 provided by, an in-network provider.
You asked the Plan to waive the copayment for acute inpatient rehabilitation care. You say that you were
unaware that the facility was not a skilled nursing facility. The Plan denied your request. The Plan says you
made no contact to the Health Plan prior to services to verify plan policy benefit. The Plan states it is the
enrollee's responsibility to contact the Health Plan prior to services to verify coverage information.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you were admitted to an in-network provider on January 21, 2019 and discharged
on February 6, 2019. You were asked to pay a $325 copayment per day from January 21, 2019 through January
25, 2019, days 1-5 of your inpatient stay. There were no copayment charges from January 26, 2019, day 6 of
your inpatient hospital care until your day of discharge January February 6, 2019. Per your contract there is a
$325 copayment per day required for days 1-5. 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 acute
inpatient rehabilitation care from January 21, 2019 through February 6, 2019 provided by, an in-network
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from September 6, 2019 to October 22, 2019.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you should only owe a $10 copayment per each visit. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient rehabilitation services provided in an outpatient hospital facility. You received outpatient rehabilitation services at an outpatient hospital facility from September 6, 2019 to October 22, 2019 for a total of 3 visits. Therefore, the total amount you owe is: $120.00. You have been asked to pay the total copayment amount of $120.00 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the Outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from September 6, 2019 to October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lenses purchased from a non-participating provider on August 3, 2019.
You asked the Plan to pay for contact lenses. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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. Based on this information, we decided that the Plan's rules for coverage of contact lenses have not been met. The provider is not in-network and your EOC clearly states, eyeglasses or contact lenses and fitting at a network optical provider (per calendar year). Therefore, we decided that the Plan does not have to pay for contact lenses purchased from a non-participating provider on August 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0879).
You asked the Plan to pre-approve Prolia. You say that the member has tried Alendronate which resulted in dysphagia. The Plan denied your request. The Plan says the step therapy exception criteria have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that there is no evidence that the member has tried and failed a trial of Reclast. Our physician reviewer found the enrollee has been taking alendronate and there is no documentation that the enrollee has been intolerant of the drug or that the drug has been ineffective. Dysphagia is not intolerance or ineffectiveness. Dysphagia of a single drug/pill, in lieu of dysphagia for any other form of oral intake (beverages, food, pills) is unlikely. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0879).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SPECT test provided on September 23, 2019.You asked the Plan to waive the copayment for the SPECT test. You say that this is a financial hardship and you cannot afford this copayment. 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 $200 copayment for in-network Medicare-covered diagnostic radiology services. You have been asked to pay a $200 copayment for the SPECT test. The SPECT test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 forSPECT test provided by on September 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided May 5, 2019.
You asked the Plan to pay for the ambulance services. You say that the services were properly billed and medically necessary. The Plan denied your request. The Plan says the enrollee's auto insurer has already paid the allowable amount on the claim.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan cannot be held responsible for the ambulance services until the primary insurer has denied the claim for these services. The record shows the auto insurer already has paid the allowable amount for the ambulance claim. Therefore, we decided that the Plan does not have to pay for ambulance services provided May 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for A7030), A7037, A7038 and A7039 provided to the enrollee on August 23, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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 DME have not been met. Healthcare Common Procedure Coding System (HCPCS) code A7038 NU KX remains not supported. The documentation submitted did not include a valid physician order. In addition, the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. Therefore, the billed supplies codes cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. HCPCS code A7030 NU KX remains not supported. The documentation submitted did not include a valid physician order. Therefore, the billed supplies codes cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. HCPCS code A7037 NU KX remains not supported. The documentation submitted did not include a valid physician order. Therefore, the billed supplies codes cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. HCPCS code A7039 NU KX remains not supported. The documentation submitted did not include a valid physician order. Therefore, the billed supplies codes cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for A7030), A7037, A7038 and A7039 provided to the enrollee on August 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay at the hospital from May 2, 2019 to May 3, 2019
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were only in the emergency room and not admitted. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $370 copayment for days 1-5 for inpatient hospital care. The medical records show that you had an inpatient hospital stay from May 2, 2019 to May 3, 2019. Therefore, you are responsible to pay the $370 copayment. You have been asked to pay a $370 copayment for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 for an inpatient hospital stay at the hospital from May 2, 2019 to May 3, 2019
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the out-of-network services. You say that the employees are rude and unprofessional. The Plan denied your request. The Plan says the service requested may be provided by a participating 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 home health aide services to be provided by an out-of-network (OON) provider.
MAXIMUS Federal Services read your letter and knows that you may have a quality of care concern. MAXIMUS Federal Services cannot address quality of care grievance. Please contact the plan regarding your grievance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora PCD (E0676) provided to the enrollee on July 23, 2019.You asked the Plan to pay for the PCD. You say that the claim should be paid.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the health plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora PCD (E0676) provided to the enrollee on July 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for monovisc for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the drug is not eligible for a tier exception.
The Plan must follow Medicare rules. The rules say that if payment for a drug could be available under Part A or Part B to the individual for such drug, then it will not be covered under Part D. The requested services are a tier exception for monovisc. Monovisc is a Part B covered drug and is therefore not eligible for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception for monovisc for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forsupply allowance for therapeutic CGM, includes all supplies and accessories, 1 month supply = 1 unit of service (CPT Code K0553) and receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (CPT Code K0554) provided to the enrollee on August 16, 2019.
You asked the Plan to pay forthe DME. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported by the records.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 DME have not been met.Healthcare Common Procedure Coding System (HCPCS) code K0553-KX-CG-KF remains not supported. The Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted. Of note, the Proof of Delivery is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified.HCPCS code K0554-NU-KX-CG-KF remains not supported. The Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted. Of note, the Proof of Delivery is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay forsupply allowance for therapeutic CGM, includes all supplies and accessories, 1 month supply = 1 unit of service (CPT Code K0553) and receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (CPT Code K0554) provided to the enrollee on August 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided to the enrollee on September 5, 2019.You asked the Plan to pay forthe orthosis. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.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 forwrist hand orthosis (L3916) provided to the enrollee on September 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on September 6, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the out-of-network
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are
being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $265
copayment for ambulance services.
You have been asked to pay a $265 copayment for ambulance services. Ambulance services fall within the
ambulance services benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services
provided on September 6, 2019.