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

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device  provided from May 15, 2019 to August 3, 2019.You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plandenied your request. The Plan says services were misrepresented.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made severalattempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and theProof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device  provided from May 15, 2019 to August 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the hand surgery provided on May 7, 2019.
You asked the Plan to waive the coinsurance for the hand surgery. You say that this surgery was necessary and it should be covered. You say you cannot afford this bill. 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). The member's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. The member has been asked to pay $1,317.40 which is 20% of the allowed amount for the hand surgery. The allowed amount is $6,587.02. ($6,587.02 x 20% = $1,317.40). The hand surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that the member has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the member agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the hand surgery provided on May 7, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided to the enrollee on May 1, 2019.You asked the Plan to pay for emergency room services. The Plan denied your request. The Plan says the member enrolled in hospice on April 09, 2019 until May 01, 2019then re-enrolled in hospice on May 02, 2019. Original Medicare is responsible for payment.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. The Plan says Original Medicare is responsible for payment of all Medicare-covered services related or unrelated to the member's terminal illness. ended 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 foremergency room services provided to the enrollee on May 1, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF care provided to the enrollee from July 30, 2019 through August 31, 2019.You asked the Plan to waive the copayment forSNF care. You say that the enrollee should not be responsible for the copay because you were told the appeal approved and there would be no charges for the SNF.The Plan denied your request. The Plan says the services were approved for the stay and the member would be responsible for the deductible and coinsurance, or any convenience services or items normally not covered by Medicare. The Plan states the claim was processed according to the plan benefit and a total of $2,236.00 ($172.00 x 13 days past day 20) for a total of 33 days is due to the provider. The Plan states charges apply to member's $4,950.00 annual maximum out of pocket expense.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). According to the 2019 EOC, Days 1-20: $0 copay per day, Days 21-100: $172 copay per day. The plan shows that the claim was processed according to the plan benefit and a total of $2,236.00 ($172.00 x 13 days past day 20) for a total of 33 days is due to the provider. Charges apply to member's $4,950.00 annual maximum out of pocket expense. This means that the enrolleehas been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrolleeagreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forSNF care provided to the enrollee from July 30, 2019 through August 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on July 30, 2019.

You asked the Plan to pay for the eyeglasses. You say that the doctor said your right vision had deteriorated faster than your left vision so you needed new glasses due to diminished vision.The Plan denied your request. The Plan says this request exceeds the benefit limit.

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 routine eye wear coverage is limited to 1 pair of standard lenses and frames every 2 years.

We looked at the file and the Plan's rules. You are allowed 1 pair of eyeglasses every 2 years. Records show that you received a pair of eyeglasses on February 20, 2018. You are not eligible for coverage of another pair of glasses until February 20, 2020. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met.Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased from on July 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 6, 2019 to October 25, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 6, 2019 to October 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for(CPT Code 99291) provided to the enrollee on April 23, 2019.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the medical records do not support this service.The Plan must follow Medicare rules. Medicare rules say that providers mustreport services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 99291 is not supported in the medical record. Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported. The documentationsubmitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The documentation does not include the time spent providing this service; therefore, the billed Critical Care Evaluation and Management code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not have to pay for(CPT Code 99291) provided to the enrollee on April 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from
December 1, 2019 through December 19, 2019.
You asked the Plan to pay for inpatient mental health care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient mental health care. Our physician
reviewer found the health plan's denial of continued inpatient psychiatric services is appropriate. This enrollee
did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger
to herself or others and did not have any auditory or visual hallucinations while being cooperative with
treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear
that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis
beyond the date in question. I am unable to find an individualized treatment plan however the entire chart is not
present. It did appear that the records were supervised and evaluated by a physician. Based upon review the
records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental
health treatment for the dates in question of December 1, 2019 forward as this patient was not shown to be a
danger to herself or others. She was not showing any auditory or visual hallucinations and was
cooperative/compliant with treatment while not showing any aggressive behaviors.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the
Plan does not have to pay for inpatient mental health care provided to the enrollee from December 1, 2019
through December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from June 13,
2019 to September 1, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that valid
proof of delivery was not submitted.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a
tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the
diabetic supplies provided to the enrollee from June 13, 2019 to September 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on October 7, 2019.You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that according to your EOC and insurance card, you are entitled to 1 cleaning and 1 bitewing x-ray per year.The Plan denied your request. The Plan says the benefits for these services have been satisfied and the frequency limitation has been exceeded.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, exams and prophylaxis are each limited to one procedure per calendar year. The record shows that you received a periodic oral evaluation and prophylaxis on April 29, 2019 and your exams and prophylaxis benefits were then exhausted.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on October 7, 2019.This decision was only based on the services rendered on October 7, 2019. Please contact the Plan with any questions regarding the services rendered on April 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on August 2, 2019.You asked the Plan to pay forthe ambulance services. You say that the service was medically necessary.The Plan denied your request. The Plan says you did not request 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 services at issue in this appeal. The Plan did not pre-approve the service 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 forthe ambulance services provided on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the measurement of the eye provided on August 27, 2019.You asked the Plan to waive the copayment for the measurement of the eye. You say that this was a routine eye exam and you should not be responsible for the charges.The Plan denied your request. The Plan says theclaims 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 $90 copayment for each diagnostic procedure or test. The medical records show that you received the measurement of the eye on August 27, 2019. Therefore, you are responsible to pay the $90 copayment. You havebeen asked to pay a $90 copayment for the measurement of the eye. The measurement of the eye falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amountbased on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe measurement of the eye provided on August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to "the beneficiary" by an out-of-network provider on August 7, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlinedin the enrollee's EOC.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 atissue. 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 forthe medical services provided to "the beneficiary" by an out-of-network provider on August 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on January 22, 2019 to April 24, 2019 by out of network provider.
You asked the Plan to pay for drug testing. You say that the out of network provider is a reference lab that performs services recommended by the referring physician. You say that the out of network provider receives specimens along with the referring physician's signed requisition from validating medical necessity. The Plan denied your request. The Plan says the records received do not support an urgent or emergent need, nor does it support a medical necessity. The Plan says the provider is an out-of-network provider. The Plan further says this testing requires prior authorization because it was not urgent or emergent and not was it medically necessary.
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 drug testing (G0483) provided on January 22, 2019 to April 24, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora home visit (99349) provided on June 6, 2019 by out of network provider.You asked the Plan to pay fora home visit. You say that you should be paid the allowed amount for this service.The Plan denied your request. The Plan says this service was 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 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 fora home visit (99349) provided on June 6, 2019 by out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services from January 2, 2019 through June 4, 2019.
You asked the Plan to pay for the transportation services. You say that the Plan coordinator stated the transportation and hotel accommodations needed for kidney transplant would be reimbursed. The Plan denied your request. The Plan says outreach was made November 21, 2019 to inform you that in order for claim reimbursement, a receipt for paid services would need to be submitted. The Plan states the receipt has not been received.
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 transportation services have not been met. Outreach was made November 21, 2019 to inform you that in order for claim reimbursement, a receipt for paid services would need to be submitted. The Plan states the receipt has not been received. In order for reimbursement to be distributed the Plan must have a receipt for all the dates of services that you are appealing. The letter from the driver is not a valid receipt of payment. Therefore, we decided that the Plan does not have to pay for the transportation services from January 2, 2019 through June 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTecentriq (J9022).You asked the Plan to pre-approveTecentriq. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Tecentriq. Our reviewer says that the medication is not medically necessary. Our physician reviewer found switching to another PD-L1 inhibitor, such as Tecentriq, is not considered a standard of care and is not supported by major drug compendia or the medical literature. The service is not reasonable or 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 Tecentriq have not been met.Therefore, we decided that the Plan does not have to pre-approveTecentriq (J9022).
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 on June 27, 2019, and July 12, 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 on June 27, 2019, and July 12, 2019.