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

We decided that the Plan does not have to pay for the ostomy supplies provided on September 27, 2019 by an out of network provider.
You asked the Plan to pay for the ostomy supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization for the supplies.
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 ostomy supplies provided on September 27, 2019 by an out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage forcontinued skilled nursing facility (SNF) services.You asked the Plan to provide coverage forcontinued skilled nursing facility (SNF) services. You say that continued SNF care is medically necessary.The Plan denied your request. The Plan says you have exhausted the 100-daybenefit.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from July 24, 2019 through April 1, 2020. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days ina row.Therefore, we decided that the Plan does not have to provide coverage forcontinued skilled nursing facility (SNF) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a ventilator. You say that the enrollee has chronic respiratory failure with hypoxia, and the equipment is life sustaining. The Plan denied your request. The Plan says a ventilator is not considered reasonable and necessary for the treatment of obstructive sleep apnea.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a ventilator. Our physician reviewer found that you have severe COPD and lung cancer. The most recent arterial blood gases test, which is from almost a year ago, does not show hypercarbia. Medicare does not cover ventilators when used as BiPAP devices. Therefore, a home ventilator is 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 a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for PT provided from October 23, 2019 to November 13, 2019.
You asked the Plan to waive the copayments for PT. You say that you disagree with the charges because you needed a surgery not PT. 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 $30 copayment for outpatient rehabilitation services. You received PT from October 23, 2019 to November 13, 2019 for a total of 6 visits. Therefore, the total amount you owe is: $30 (copayment) x 6 (PT visits) = $180. You have been asked to pay the total copayment amount of $180 for PT. PT falls 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 PT provided from October 23, 2019 to November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a non-radiological test provided on December 16, 2019.
You asked the Plan to waive the copayment for a non-radiological test. You say that you disagree with the 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 $10 copayment for laboratory tests, non-radiological tests, diagnostic tests and ultrasounds. You have been asked to pay the allowed amount of $4.10, which is less than the $10 copayment for a non-radiological test. A non-radiological 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 for a non-radiological test provided on December 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital admission for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says there is no inpatient treatment required, and you are receiving comfort care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Inpatient admission is not medically necessary. The enrollee's current care is custodial, pending placement in a skilled nursing facility. The enrollee has been medically stable, with the primary treatment plan to be secure long term placement in a nursing facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital admission for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the hand held low vision aid (V2600) provided by out of network (OON) provider on February 1, 2019.
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item was provided 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 issue reimbursement for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to issue reimbursement for this item. Therefore, we decided that the Plan does not have to issue reimbursement for the hand held low vision aid (V2600) provided by the out of network (OON) provider on February 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on September 21, 2019.You asked the Plan to waive the copayment for an urgent care visit. You say that you were bleeding and the services were necessary.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 $65 copayment for urgently needed services. You have been asked to pay a $65 copayment for an urgent care visit. An urgent care visit falls within the urgently needed 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 an urgent care visit provided on September 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on May 28, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on May 28,
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient substance abuse services rendered to you from January 16, 2019 to February 14, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the provider is not Medicare-certified.The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program.The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe inpatient substance abuse services rendered to you from January 16, 2019 to February 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 November
5, 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 providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 80307 and HCPCS G0483 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 November 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto for the enrollee.You asked the Plan to pre-approve Entresto. You say that Entresto is medically necessary.The Plan denied your request. The Plan says Entresto is not covered under Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveEntresto for the enrollee.Benefits for self-administered drugs may be available under the Medicare Part D benefit. Please contact the enrollee's prescription drug carrier for further information.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 19, 2019.
You asked the Plan to pay for lab services. You say that hospice services were revoked when the services were rendered. The Plan denied your request. The Plan says Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 11, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive vision exam (92004) and refraction (92015) provided November 19, 2019.
You asked the Plan to pay for vision. You say that you were given the ophthalmologist name by a social worker and the provider's office said they take this plan and now you're being told the appointment is not covered. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-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. The Plan covers these services when provided by an in-network provider.
We looked at the file and the Plan's rules. enrollee's must receive vision services from an in-network provider. Based on this information, we decided that the Plan's rules for coverage of vision have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive vision exam (92004) and refraction (92015) provided November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grade 1 power operated vehicle for the enrollee.
You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee is unable to move around the home, and is unable to transfer to the scooter
without assistance.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 vehicle. Our reviewer says that the
requested vehicle is not medically reasonable or necessary. Our physician reviewer found the enrollee has a
personal mobility deficit but the documentation is not clear that it impairs participation in MRADLs. The
enrollee's mobility deficit be helped by the use of a walker as the physician document notes he can walk 30 feet
with a wheeled walker. The documentation is conflicting. The physician note does not reveal that the enrollee
can safely operate a PMD as the physician note indicates he cannot use the scooter in the home and is unable to
transfer to the power mobility device without assist.
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 vehicle have not been met. Therefore, we decided that the Plan does not
have to pre-approve a grade 1 power operated vehicle for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health services.You asked the Plan to pre-approvehome health services. You say that you can barely walk.The Plan denied your request. The Plan says there is no indication that you are homebound, or require skilled nursing services.The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be covered. The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-approvehome health services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 25, 2019 through December 2, 2019. You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because per CMS, CPT code S9328 is valid. The Plan denied your request. The Plan says CPT code S9328 has a status indicator of I and is not valid for Medicare purposes. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 25, 2019 through December 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for adjacent tissue transfer services (CPT 14301 and 14302) provided to the enrollee on October 16, 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 denied codes are not supported by the records submitted.
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: CPT 14301: adjacent tissue transfer or rearrangement of any area, for defects 30.1 sq cm to 60.0 sq cm CPT 14302: adjacent tissue transfer or rearrangement of any area, for each additional 30.0 sq cm, or part thereof (listed separately in addition to code for primary procedure) 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the medical records provided do not include documentation to meet the NCCI Policy manual description of an Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. Therefore, CPT 14301 is not supported by the medical records. The medical records provided do not include documentation to meet the NCCI Policy manual description of an Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). Therefore, CPT 14302 is not supported by the medical records submitted. 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 services have not been met. Therefore, we decided that the Plan does not
have to pay for adjacent tissue transfer services (CPT 14301 and 14302) provided to the enrollee on October 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on November 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that these services were medically necessary. You say that you would like the claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 tests provided on November 12, 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 naturopathy services provided by the
Physicians from March 21, 2019 to August 13, 2019.
You asked the Plan to pay for naturopathy services. You say that your goal is to feel good without taking
medications that come with side-effects that create other medical issues. The Plan denied your request. The
Plan says the denial of payment for these services is correct, because naturopathy services are not covered by
Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have
to pay for naturopathy services provided by the Physicians from March 21, 2019 to August
13, 2019.