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

We decided that the Plan does not have to pay for the advance care planning including the explanation and discussion, and the hospital discharge day management provided on August 29, 2020.
You asked the Plan to pay for the physician services. You say that the services should be paid. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the advance care planning including the explanation and discussion, and the hospital discharge day management provided on August 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on October 27, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you previously received this service with a different provider. The Plan denied your request. The Plan says you have reached the frequency limit for this service.
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, you are limited to one comprehensive oral exam every 36 months. The record shows that you received a comprehensive oral evaluation on January 13, 2020 and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on August 10, 2020.
You asked the Plan to pay for drug testing. You say that this is supported by the records. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The service at issue was reported with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on August 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided by an out of network (OON) provider.

You asked the Plan to pay for pathology services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services 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 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 had network providers available who could have provided 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 pathology services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided by an out-of-network provider.

You asked the Plan to pay for the eye exam. You say that a provider performing services in a nursing home is not responsible to obtain authorization. You say that the provider should be reimbursed for all services rendered. The Plan denied your request. The Plan says prior authorization was not 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 had network providers available who could have provided 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 eye exam provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for new patient ophthalmological services, medical examination and evaluation (92002) deluxe frames (V2020x2) external ocular photography (92285).

You asked the Plan to pay for the vision services. You say that the provider wrote the wrong prescription twice but took your money in the amount of $224.89 that you paid to him. The Plan denied your request. The Plan says the eyewear benefit for the 2020 year has been exhausted. You must use in network providers for covered vision services.

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 1 routine eye exam per calendar year and a $200 eyewear benefit toward the purchase and fitting of eyeglasses (frames and lenses) or contact lenses per calendar year. The eye exam and eyewear benefit was provided and the plan covered on date of service. Therefore, the benefit has been exhausted.

We looked at the file and the Plan's rules. The plan contract says that the plan covers only 1 routine eye exam per calendar year and a $200 eyewear benefit toward the purchase and fitting of eyeglasses (frames and lenses) or contact lenses per calendar year. You are responsible for any amount over the $200 eyewear benefit. Covered vision services must be rendered by an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for new patient ophthalmological services, medical examination and evaluation (92002) deluxe frames (V2020x2) external ocular photography (92285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397).
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that these items were medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there is no evidence the prescribing physician saw the enrollee.
The Plan follows Medicare rules. Medicare rules say that the spinal orthosis is subject to the criteria listed in the Medicare rules section. 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 knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically necessary and reasonable. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is insufficient documentation of a credible physician evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the molecular genetic testing.

You asked the Plan to pay for the testing. You say that you would like reconsideration because your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says that molecular genetic screening testing is not a Medicare benefit for the diagnosis as listed on the claim.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.

This testing was ordered by a contract provider. The file does not show that the plan provided notice that the testing would not be covered. Under Medicare rules, this means the testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the molecular genetic testing.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on September 17, 2020.
You asked the Plan to waive the copay for the ambulance transport. You say that you should not be held responsible for these charges. The Plan denied your request. The Plan says that the copay processed 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 $275 copay for each Medicare-covered one-way trip via ground ambulance. You have been asked to pay a $275 copay for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way trip via ground ambulance 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 copay for the ambulance transport provided on September 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous transcatheter closure of the left atrial appendage with an endocardial implant (watchman device) (33340).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.
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 this item. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that it is noted in the documentation provided that the patient forgets to take his medication occasionally in the evenings. The documentation does not suggest there is no other less invasive means to help the patient to take their evening dose such as nursing services, a pill box, or other simple intervention. There is no contraindication to oral anticoagulation therapy alone. Therefore, this request for a percutaneous atrial appendage closure surgery with a watchman device will be considered not medically necessary based on the provided documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous transcatheter closure of the left atrial appendage with an endocardial implant (watchman device) (33340).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99203) provided on
November 2, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you should not have a copayment
because the doctor refused to treat you if you did not wear a mask. The Plan denied your request. The Plan says
this processed 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 $45
copayment for specialist visits.
You have been asked to pay a $45 copayment for an office visit. The submitted medical records confirm that
this service was performed. 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 office visit (99203)
provided on November 2, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on November 12, 2020.
You asked the Plan to pay for the infectious agent detection by nucleic acid. You say that you have no knowledge of the enrollee's coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 the infectious agent detection by nucleic acid provided on November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post-stabilization care.

You asked the Plan to pay for the post-stabilization care. You say that the inpatient services were medically
necessary. The Plan denied your request. The Plan says the enrollee was stable.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.

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 post-stabilization care. Our reviewer says
that the service was not medically necessary. Our physician reviewer found the post-stabilization care services 
at the non-Plan facility were not medically necessary or reasonable. The treating physician did not document 
(in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.

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 post-stabilization care have not been met. Therefore, we decided that the
Plan does not have to pay for the post-stabilization care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Home Health Physical Therapy visits.
You asked the Plan to pre-approve the Physical Therapy visits. You say that you would like reconsideration because Physical Therapy is required for the member to achieve independence and the member is not able to walk the distance to get to a rehabilitation facility. The Plan denied your request. The Plan says the member's current needs do not appear to be skilled in nature.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 Physical Therapy visits. Our reviewer says that the documentation doesn't support that the member requires additional skilled rehab services to provide treatment that is medically necessary. Our physician reviewer found the member does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Her function is at or near her baseline and she does not require any further skilled rehab therapy.
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 Physical Therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve Home Health Physical Therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous (IV) tubing and infection control supplies rendered on August 28, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure codes S1015 (IV tubing set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the intravenous (IV) tubing and infection control supplies rendered on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neurology services provided on July 27, 2020, to September 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for neurology services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that there are in-network providers available 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 had network providers available who could have provided 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 neurology services provided on July 27, 2020, to September 25, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care.

You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a limited orthodontic treatment of the adult dentition (D8040).
You asked the Plan to pre-approve the dental service. You say that this service is not for aesthetic. You say that you need the provider to put wire between your teeth to make space so that you can get an implant. You also say that you were advised that if you specified this is what the service was for, then it would be approved. The Plan denied your request. The Plan says limited orthodontic treatment of the adult dentition is not a covered service.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a limited orthodontic treatment of the adult dentition (D8040).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a blepharoplasty (67900).

You asked the Plan to pre-approve the blepharoplasty. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that blepharoplasty is covered when medically necessary.

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 blepharoplasty. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found the documentation does not demonstrate visual field correction. The records do not support that coverage criteria has not been met.

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 blepharoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a blepharoplasty (67900).