Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 2, 2019.
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 provided on December 2, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran emergency department (ED) visit (99282) provided on June 15, 2019 by the in-network provider.You asked the Plan to waive the copayment forthe ED visit. You say that you should not be responsible for the copayment since you left prior to seeing a doctor due to the long wait time.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $90 copayment for emergency care.You have been asked to pay $75.88 (the allowed amount) for the ED visit. An ED visit falls within the emergency care 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 foran emergency department (ED) visit (99282) provided on June 15, 2019 by the in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora face-down positioning device (E1399) purchased October 21, 2019.You asked the Plan to pay fora face-down positioning device. You say that you do not know why the Plan would deny your claim for reimbursement of post-operative equipment that is designed to enhance the success of a medical eye operation.The Plan denied your request. The Plan says this item is not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. These types of devices are considered precautionary devices and also can be used for purposes other than the treatment of an illness or injury.Therefore, we decided that the Plan does not have to pay for a face-down positioning device (E1399) purchased October 21, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and ambulance service provided on October 19, 2019.
You asked the Plan to pay for the ground mileage and ambulance service. You say that the enrollee was transported for injuries sustained from a fall that was unrelated to his reason for hospice care. 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 ground mileage and ambulance service provided on October 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira Pens.
You asked the Plan to pre-approve the Humira Pens. You say that this drug is medically appropriate and necessary. You also say that the enrollee has been on Humira long term with a good response to therapy. The Plan denied your request. The Plan says this is a drug that the enrollee would take at home. The Plan also says that self-administered drugs are not covered by 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-approve Humira Pens.
Benefits for the Humira Pens 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on October 31, 2019 by an out of network provider.
You asked the Plan to pay for the dental service. You say that you had to see a different provider for this appointment. You say that your usual provider passed away. You say you were not aware of this prior to your appointment. You also say that the provider office is under a new name now. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says you must use a network provider for the services to be covered.
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 pay for the prophylaxis provided on October 31, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on November 21, 2018.You asked the Plan to pay for the office visit. You say that you would like reconsideration because the claim was submitted as early as the end of 2018.The Plan denied your request. The Plan says a claim cannot be processed if it is received after the timely filing time frame which is 1 year after the date of service.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the office visit was not filed until January 2, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay foran office visit (99214) provided on November 21, 2018.Your complaint about mishandling of your claim is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9501) provided from December 28, 2019 to December 31, 2019.You asked the Plan to pay for home infusion therapy. You say that this code has previously been paid.The Plan denied your request. The Plan says this code 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 S9501 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9501) provided from December 28, 2019 to December 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $200 copayment charged for ambulance transport provided to the enrollee on August 6, 2019.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the service provided and the Plan contract agreement.
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 enrollee's contract with the Plan clearly says that enrollees must pay $200 copayment for each ambulance transport one way. The enrollee has been asked to pay $200 copayment for this copayment. The enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the $200 copayment charged for ambulance transport provided to the enrollee on August 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and X-Ray examinations provided from November 8, 2019 to November 22, 2019.
You asked the Plan to pay for dental services. You say that you were told these were medical procedures and would be billed as such. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by the Plan.
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 pay for an office visit and X-Ray examinations provided from November 8, 2019 to November 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after April 20, 2020.
You asked the Plan to pre-approve continued SNF coverage. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued SNF coverage. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee required minimal assistance to contact guard assistance with functional mobility including walking to 60 feet times two with a rolling walker. The enrollee had ongoing cognitive impairment. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF level of care.
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 SNF coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the observation stay provided from October 22, 2019 through October 24, 2019.
You asked the Plan to waive the coinsurance for the observation stay. You submitted your bill for review. The Plan denied your request. The Plan says the coinsurance 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 will pay 20% (or other indicated cost-sharing) if you are in a Medical Assistance category that does not cover payment of the applicable Medicare cost-sharing amounts. You have been asked to pay $340, which is 20% of the allowed amount for the observation stay. The allowed amount is $1,700 (20% x $1,700 = $340). The observation stay 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 coinsurance for the observation stay provided from October 22, 2019 through October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 7, 2019 to November 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office services. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 7, 2019 to November 19, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean oxygen concentrator, portable oxygen contents and portable gaseous O2.You asked the Plan to pre-approvethese services. The Plan denied your request. The Plan says that notes do not show you have abnormal low level of oxygen in the blood.The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.  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 these services. Our reviewer says that these services are not medically reasonable and necessary in this case. The most recent documentation notes a pO2 of 59 and an O2 saturation of 90.1% on room air. There is no evidence of dependent edema, pulmonary hypertension, cor pulmonale or erythrocythemia. Our physician reviewer found We looked at this physician's review, the file, and Medicare rules. 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 pre-approvean oxygen concentrator, portable oxygen contents and portable gaseous O2.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metoprolol Tartrate for the enrollee.You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this medication is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare PartB 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 Metoprolol Tartrate for the enrollee.Benefits for this drug 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.You asked the Plan to pre-approve Prolia. You say that this is medically necessary.The Plan denied your request. The Plan says the enrolle has not met the step therapy requirements.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Prolia. Our reviewer says that the criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires either a history of osteoporosis-related fracture or a trial of zoledronic acid before they will approve the requested drug. The records do not show that the enrollee has a history of osteoporosis-related fracture or has tried zoledronic acid. The records also do not show that zoledronic acid would likely be less effective or have adverse effects for the enrollee.We looked at this physician'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for consultation, imaging, surgical services, and travel expenses provided from October 16, 2018 to November 4, 2018.
You asked the Plan to pay for consultation, imaging, surgical service, and travel expenses. You say that if you had not taken the situation into your own hands, you would still be suffering with a debilitating disease. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services were out-of-network, out-of-area, and not urgent or emergent in nature.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 consultation, imaging, surgical service, and travel expenses. Our reviewer says that these services do not meet the Medicare criteria for urgent out-of-area care. Our physician reviewer found there is nothing to indicate that you had an emergency. There is nothing to indicate that your need for ongoing care was unforeseen prior to leaving the Plan's service area. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of consultation, imaging, surgical service, and travel expenses have not been met. Therefore, we decided that the Plan does not have to pay for consultation, imaging, surgical services, and travel expenses provided from October 16, 2018 to November 4, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient rehabilitation services provided from October 25, 2019 to October 31, 2019.
You asked the Plan to pay for inpatient rehabilitation services. You say that you are Medicare certified. The Plan denied your request. The Plan says there is no Medicare ID on file.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that these services are not supported. Specifically, neither the NPI nor provider number were provided on the claim. The certification from CMS says that this should be reported on all correspondence. Based on this information, we decided that Medicare rules for coverage of inpatient rehabilitation services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient rehabilitation services provided from October 25, 2019 to October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device (L8702).
You asked the Plan to pre-approve the powered upper extremity range of motion assist device. You say that there are no in-network providers certified to fit and program this custom brace. You say that the documentation provided supports that the requested device is medically necessary. The Plan denied your request. The Plan says the enrollee is continuing to show gains in strength and coordination. The Plan says that the request notes that the orthotic would improve the enrollee's ability to carry heavy objects and return to work, which are not activities of daily living. The Plan says that there are notes of an ability to improve independence while bathing, but that a myoelectric device cannot be worn in the shower. The Plan says that the requested orthosis is not medically necessary at this time.
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 the powered upper extremity range of motion assist device. Our reviewer says that the requested items is not considered medically reasonable and necessary in this case. Our physician reviewer found the use of a powered upper extremity range of motion assist device is not widespread for treatment of hemiparesis after stroke based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for the enrollee, improve his hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase the enrollee's participation in bimanual activities. 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 powered upper extremity range of motion assist device have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device (L8702).