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

We decided that the Plan does not have to pay for an ankle-foot orthosis (L1906) provided to the enrollee on November 13, 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 documentation does not indicate services are necessary for treatment of the enrollee's condition.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 an ankle-foot orthosis (L1906) provided to the enrollee on November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued rental of a home ventilator.
You asked the Plan to pre-approve continued rental of a home ventilator. You say that the enrollee needs to continue with the home ventilator. The Plan denied your request. The Plan says continued rental of a home ventilator is not medically necessary.
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 continued rental of a home ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found coverage criteria for a home ventilator are not met. This enrollee has COPD with hypoxemia, but there is no documentation of increased pCO2 while in a stable state. In addition, the enrollee has not met minimum usage criteria. A home ventilator is considered not medically necessary, and the denial is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued rental of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve continued rental of a home ventilator.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay foremergency room services (99284) provided on November 20, 2019.You asked the Plan to pay forthe emergency room services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says payment for this service has already been rendered.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We looked at the file and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the emergency room services have not been met. Specifically, the record indicates that a claim for the same service, provider, date of service and amount has been previously paid.Therefore, we decided that the Plan does not have to pay foremergency room services (99284) provided on November 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided October 7 to October 17, 2019.
You asked the Plan to waive the copayment for the inpatient services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 copayment for days 1-5 up to $1,375 for inpatient care. You have been asked to pay $1,375 for the inpatient services. 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 services provided October 7 to October 17, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 6, 2019 to December 15, 2019 and from December 24, 2019 to January 4, 2020. You asked the Plan to pay for the skilled nursing services. You say that the services which 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 skilled nursing facility (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 skilled nursing 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from December 6, 2019 to December 15, 2019 and from December 24, 2019 to January 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 29, 2020.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on January 22, 2020.You asked the Plan to waive the copayment forthe specialist office visit. You say that you were told there would not be a copayment for the visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each in-network specialist office visit for Medicare-covered services. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's offices visits" 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 forthe specialist office visit provided on January 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve single-level lumbar fusion surgery.
You asked the Plan to pre-approve spinal surgery. You say that you are appealing with records. The Plan
denied your request. The Plan says the denial of authorization for this service is correct, because the evaluation
does not support that other causes for lower back pain or radiculopathy have been ruled out, no clear imaging
findings are noted, there are no clear radicular electromyography (EMG) findings noted, and no clear dynamic
instability noted.
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 spinal surgery. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no instability, fracture, or lesion. Therefore, the criteria for lumbar fusion are not 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 spinal surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve single-level lumbar fusion surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the BCG live intravesical instillation, 1 mg or waive the copayment for bladder instillation of cancer preventive inhibiting, or suppressive agent provided from October 10, 2019 to October 24, 2019.
You asked the Plan to waive the coinsurance for the BCG live intravesical instillation, 1 mg and waive the copayment for bladder instillation of cancer preventive inhibiting, or suppressive agent. You say that you would like the plan to reduce your share. The Plan denied your request. The Plan says that the cost share applied 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 20% coinsurance for each Medicare-covered Part B drug and a $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital. You have been asked to pay a 20% coinsurance for the BCG live intravesical instillation, 1 mg and less than a $295 copayment for bladder instillation of cancer preventive inhibiting, or suppressive agent. The BCG live intravesical instillation, 1 mg falls within the Medicare-covered Part B drug and the bladder instillation of cancer preventive inhibiting, or suppressive agent falls within the Medicare-covered surgery or other services provided to you at an outpatient hospital benefit category. This means that you have been asked to pay the correct amount for the BCG live intravesical instillation, 1 mg and less than the correct amount for the bladder instillation of cancer preventive inhibiting, or suppressive agent 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 BCG live intravesical instillation, 1 mg and waive the copayment for bladder instillation of cancer preventive inhibiting, or suppressive agent provided from October 10, 2019 to October 24, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment forthe laboratory work provided on January 16, 2020.You asked the Plan to waive the copayment forthe laboratory work. You say that the blood work was taken for your yearly wellness check-up. Yousay that the tests are covered and should be paid in full. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not submit the complete Evidence of Coverage to support the cost-sharing amount. This means, the plan has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment forlaboratory work provided on January 16, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aimovig.You asked the Plan to pre-approve Aimovig. You say that the enrollee reports a decrease in migraine days and decrease in severity since Aimovig initiation.The Plan denied your request. The Plan says Aimovig is a self-administered drug which falls under Part D coverage.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  Aimovig.Benefits for Aimovig 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 pre-approve a Group 2 power wheelchair and accessories.
You asked the Plan to pre-approve a Group 2 power wheelchair and accessories. You say that you need a motorized scooter. The Plan denied your request. The Plan says a scooter was not ruled out prior to the request for a Group 2 power wheelchair.
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. The authorization request and assessment was for a Group 2 power wheelchair and accessories. The file shows that you do not have a mobility deficit that impairs your participation in MRADLs and your condition can be improved by a cane. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on January 22, 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 separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe aminophyllin injection services coded J0280 provided on December 4, 2019.You asked the Plan to pay forthe aminophyllin injection services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 code J0280 is injection, aminophyllin, up to 250 mg.We find that CPT code J0280 is not supported in the medical record. Specifically, three units of this code were billed. The documentation submitted does not support the unites billed. Based on this information, we decided that Medicare rules for coverage of the aminophyllin injection services have not been met.Therefore, we decided that the Plan does not have to pay forthe aminophyllin injection services coded J0280 provided on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services received on January 23, 2020.
You asked the Plan to pay for the services. You say that you should not have to pay for this, due to the benefits you have. The Plan denied your request. The Plan says this balance of $49 can be billed by the provider's office.
Medicare rules say that plans can require enrollees to get care from network providers. 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. The rendering provider in this case is not a network provider with the Plan. Your plan contract states that you may be responsible for additional costs if you use an out-of-network provider for dental services. Therefore, we decided that the Plan does not have to pay for dental services received on January 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cataract surgery provided on October 16, 2019. You asked the Plan to waive the copayment fora cataract surgery. You say that you were told that you would only owe a $40 copayment.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 $250 copayment per day for outpatient procedures and services provided in outpatient hospital facilities or ambulatory surgical centers for outpatient hospital services. You have been asked to pay a $250 copayment for a cataract surgery. A cataract surgery falls within the outpatient hospital 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 a cataract surgery provided on October 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 29, 2019 to December 28, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition did not require daily skilled services at an inpatient skilled nursing facility (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 skilled nursing 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from November 29, 2019 to December 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on May 31, 2019.
You asked the Plan to pay for the laboratory testing. 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 laboratory testing provided on May 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 7, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for Medicare-covered primary care provider office visits. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 the office visit provided on October 7, 2019.