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

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on
May 28, 2019.
You asked the Plan to pay for the orthosis. 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 orthosis have not been met. The medical record shows that the
enrollee was seen by the provider on May 28, 2019 where he documented a full office visit and physical exam.
There is no mention in the records of any back pain or limitation of movement of the back. There is no mention
of the need for back bracing. There is an order for a back brace signed on May 20, 2019 by the provider. There
is no commensurate note in the medical record on or around that date as to why the brace was being ordered.
Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the
enrollee on May 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on July 8, 2019.
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 procedure code 28515 was not billed with the required anatomical modifier.
The Plan must follow Medicare rules. The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures performed on different anatomical sites. We looked at the file and Medicare rules. Billed procedure code 28515 was not billed with a required anatomical modifier. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on July 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 23, 2019 by an out of network (OON) provider.
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 services were rendered by an out-of-network provider without 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 August 23, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says that the enrollee is total assist and does not require further skilled services.
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 pre-approve SNF care. Our physician reviewer found that the enrollee requires oversight of his medical conditions and medication management. He is at risk for secondary complications of immobility such as pressure ulcers and contractures as well as further syncopal episodes. The enrollee does not have a history of a current pressure ulcer and currently requires assistance of more than 1 person for essential activities of daily life sitting such as bed mobility. A trial of skilled therapy is indicated. He requires both daily skilled therapy and nursing services. He is unable to perform essential activities of daily living such as bed mobility without assistance from more than one person. The enrollee's condition would be expected to deteriorate with services provided on a less than daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the gallbladder surgery provided on July 30, 2019.
You asked the Plan to waive the coinsurance for the gallbladder surgery. You say that you were not charged for a hospital stay in 2017. You say you do not know why you are being charged for the surgery on July 30, 2019. 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 10% coinsurance for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $512.30 which is less than the standard 10% of the allowed amount for the gallbladder surgery. The allowed amount is $5,353.34. the gallbladder surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 gallbladder surgery provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Hepatitis A vaccine (90632) provided on August 23, 2019.
You asked the Plan to pay for a Hepatitis A vaccine. You say that this should be covered. The Plan denied your
request. The Plan says coverage of this vaccine is the responsibility of your Part D prescription drug plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Hepatitis A
vaccine. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to a Hepatitis A
vaccine. Therefore, we decided that the Plan does not have to pay for a Hepatitis A vaccine (90632) provided
on August 23, 2019.
Benefits for a Hepatitis A vaccine may be available under Medicare Part D. Contact the 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 waive the coinsurance for portable oxygen contents, gaseous, 1 month's supply = 1 unit (CPT Code E0443) provided from May 22, 2019 through July 22, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claims were processed accordingly with your 2019 EOC benefits.
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 show that you received DME from May 22, 2019 through July 22, 2019. You have been asked to pay 20% coinsurance of the allowed amount for DME. The allowed amount is $66.38. The amount you owe per month is $13.28 ($66.38 x 20% = $13.28). You are being charged for three months; therefore, the total amount you owe is $39.84 ($13.28 x 3 months = $39.84). 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 portable oxygen contents, gaseous, 1 month's supply = 1 unit (CPT Code E0443) provided from May 22, 2019 through July 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services outside of the United States from
October 18, 2019 through October 21, 2019.
You asked the Plan to pay for the medical services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 medical services have not been met. For urgently needed
services the coverage is limited to the United States and its territories. Per your itinerary, your cruise ship was
in Mexico and/or international waters on the dates of service. Therefore, we decided that the Plan does not have
to pay for the medical services outside of the United States from October 18, 2019 through October 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services provided from August 3, 2018 to September 1, 2018.
You asked the Plan to pay for the SNF services. You say that the services that the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.
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 SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the SNF services provided from August 3, 2018 to September 1, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hip orthosis (L1686) and addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each (L2624) provided to the enrollee on September 11, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member & 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 hip orthosis (L1686) and addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each (L2624) provided to the enrollee on September 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on May 28, 2019.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were in-network providers available. These out-of-network services were not pre-authorized and were not emergent.
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 physician services provided on May 28, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gastrointestinal (GI) testing services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON GI testing. You say that the enrollee needs these services to determine their condition. The Plan denied your request. The Plan says there is no medical reason noted that this testing cannot be provided by a network GI 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 the gastrointestinal (GI) testing services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity 1.5mg/0.5ml pen (C9399).
You asked the Plan to pre-approve Trulicity 1.5mg/0.5ml pen. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Trulicity 1.5mg/0.5ml pen (C9399).
Benefits for Trulicity 1.5mg/0.5ml pen may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from July 3, 2019, to September 4, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from July 3, 2019, to September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prescription lenses purchased on April 1, 2019 from an out-of-
network provider.
You asked the Plan to pay for the prescription lenses. You say that you are requesting reimbursement for the
prescription lenses purchased. The Plan denied your request. The Plan says you do not have out-of-network
benefits and you self-referred yourself to this out-of-network provider.
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 the prescription lenses have not been met. The provider is not in-network and your EOC clearly
states, supplemental (i.e., routine) vision services must be received from a participating provider in order to be
covered by the plan. Therefore, we decided that the Plan does not have to pay for prescription lenses purchased
on April 1, 2019 from an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on October 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for radiology services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization is required for these services. The Plan says that no prior authorization was obtained for these 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 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 radiology services provided on October 15, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained for these 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 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 an office visit provided on September 9, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 10, 2019 through October 15, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
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 October 10, 2019 and discharged on October 15, 2019. You were asked to pay a $200 copayment per day from October 10, 2019 through October 13, 2019, days 1-4 of your inpatient stay. There were no copayment charges from October 14, 2019, day 5 of your inpatient hospital care until your day of discharge October 15, 2019. Per your contract there is a $200 copayment per day required for days 1-4. 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 inpatient hospital care from October 10, 2019 through October 15, 2019 provided by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical boot/shoe, each (CPT Code L3260) provided on November 1, 2019.
You asked the Plan to pay for the surgical boot/shoe, each. You say that the doctor recommended the DME. The Plan denied your request. The Plan says the orthotic device is not a prosthetic show, diabetic shoe insert, or diabetic footwear. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for surgical boot/shoe, each (CPT Code L3260) provided on November 1, 2019.