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

We decided that the Plan does not have to pay forthe home infusion therapy rendered to enrollee from October 24, 2019 to October 31, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusiontherapy rendered to enrollee from October 24, 2019 to October 31, 2019.Benefits for these servicesmay 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 pay for straight tip urine catheters (A435x600) provided on September 24, 2019.
You asked the Plan to pay for the straight tip urine catheters. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the number of units billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code A4351x600 is not supported in the record. Specifically, the claim indicates that you are requesting payment for 600 units of CPT code A435. The proof of delivery indicates that a total of 260 units were delivered. Based on this information, we decided that Medicare rules for coverage of the straight tip urine catheters have not been met. Therefore, we decided that the Plan does not have to pay for straight tip urine catheters (A435x600) provided on September 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on November 25, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you do not understand why you have to pay so much for the procedure.The Plan denied your request. The Plan says the copayment 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 $400 copayment for in-network, Medicare-covered outpatient hospital surgery services.You have been asked to pay a $400 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that a polyp was removed during the colonoscopy, which is considered a surgical procedure. 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 colonoscopy provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on September 27, 2019.You asked the Plan to waive the copayment for an outpatient hospital visit. You say that you feel that you should only owe a $25 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 $325 copayment for outpatient hospital and observation services. You have been asked to pay the allowed amount of $87.04, which is less than the $325 copayment for an outpatient hospital visit. An outpatient hospital visit 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 an outpatient hospital visit provided on September 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to enrollee on August 23, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95999 is not supported.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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the file shows that train of four testing was performed and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the services rendered to enrollee on August 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Iris Vision electronic glasses.
You asked the Plan to pre-approve the glasses. You say that this is medically necessary. The Plan denied your request. The Plan says neither Medicare nor the plan covers this item.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pre-approve Iris Vision electronic glasses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bone growth stimulator rendered to enrollee on May 29, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary.We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe bone growth stimulator rendered to enrollee on May 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from September 30, 2018 through October 5, 2018.You asked the Plan to waive the copayment for the inpatient stay. You say that the impact should have been taken care of during your first stay.The Plan denied your request. The Plan says the copayment 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 $395 copayment each day for days 1 to 4 for in-network, Medicare-covered hospital care and a $0 copayment for additional Medicare-covered days.You have been asked to pay a $1,580 copayment for the inpatient stay. ($395/day x first 4 days = $395). The inpatient stay falls within the "Inpatient Hospital 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 for the inpatient stay provided from September 30, 2018 through October 5, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on October 24, 2019.You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with the charges because you have had polyps removed in the past and were never charged a 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 $290 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The record shows that you had polyps removed during a colonoscopy on October 24, 2019. Therefore,the colonoscopy is considered diagnostic, not preventative and you are responsible to pay the $290 copayment. You have been asked to pay a $290 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy provided on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter.
You asked the Plan to pre-approve these services. You say that you are at risk for falls. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a crutch substitute is denied by Medicare as not medically necessary. We looked at the file and Medicare rules. The requested item is a knee scooter, also called a crutch substitute, described by procedure code E0118. This item is denied by Medicare as not medically necessary. 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-approve a knee scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on August 22, 2019.You asked the Plan to waive the deductible for the office visit. You say that you were referred by your primary care physician. You say that you were informed the provider was in-network.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Out-of-network office visits are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to out-of-network office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on August 22, 2019.Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on August 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (pain pump therapy) (S9328) provided to the enrollee from September 5, 2019 through October 28, 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 Medicare rules have not been met.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9328 is not supported in themedical record. Specifically, we find that CPT code S9328 is not supported for payment. Specifically, this code is not valid for Medicare purposes. Medicareuses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (pain pump therapy) (S9328) provided to the enrollee from September 5, 2019 through October 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic screening testing provided by MyTest Diagnostics on February 19, 2020.You asked the Plan to pay forscreening tests. You say that you are appealing with supporting documentation.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the enrollee's treating physician did not order these tests and the enrollee did not have any signs or symptoms to indicate testing was medically necessary.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The tests at issue in this appeal, screening tests, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes.Therefore, we decided that the Plan does not have to pay forgenetic screening testing provided by MyTest Diagnostics on February 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient diagnostic tests provided on September 19, 2019.
You asked the Plan to waive the coinsurance for outpatient diagnostic tests. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for diagnostic procedures and tests. You received outpatient diagnostic tests on September 19, 2019. The total allowed amount is $834.66 and 20% of that is $166.93. You have been asked to pay the total coinsurance amount of $166.93 for outpatient diagnostic tests. Outpatient diagnostic tests fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for outpatient diagnostic tests provided on September 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dalfampridin forthe enrollee. You asked the Plan to pre-approveDalfampridin. You say that the medication has been effective in controlling the enrollee's symptoms.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.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-approveDalfampridin for the enrollee. Benefits for Dalfampridinmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient psychiatric care provided from July 10, 2019 to July 11, 2019.
You asked the Plan to pay for inpatient psychiatric care. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services do not meet the inpatient level of care criteria and are supported for outpatient level of care instead.
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 psychiatric care. Our reviewer says that these services do not meet the Medicare criteria for coverage. Our physician reviewer found based upon the records provided it was not expected that this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the enrollee did not have dangerousness to self or others and was compliant with treatment. The Plan's denial of inpatient psychiatric services is
appropriate. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonable expected to improve the enrollee's condition or for the purpose of diagnosis. The enrollee was treated by an individualized treatment plan found in the medical record. These services were supervised and evaluated by a physician. 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 psychiatric care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient psychiatric care provided from July 10, 2019 to July 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on August 23, 2019.You asked the Plan to pay forthe ambulance services. You say that the Plan should pay these claims.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you haveasked the Plan to pay for are ambulance transport services to a doctor's officeand back.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on August 23, 2019.
Appeal type: Home Health
Decision: Favorable

We decided that the Planhasto pre-approvecontinuous home care services (30 days of palliative care) for the enrollee.You asked the Planto pre-approvehome health services. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthis is not a covered benefit.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 home health services. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee is noted to be receiving skilled nursing services while on home Hospice. Ongoing coverage for home health aide servicesto assist with ADLs has been requested. It appears that the enrollee has been receiving these services on an intermittent basis to meet his personal care needs (i.e. grooming, bathing). These services appear to be medically necessary and reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have been met.Therefore, we decided that the Planhas to pre-approvecontinuous home care services (30 days of palliative care) for the enrollee. If the Plandoes 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/orsend us the new information. This doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex spacer for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has back pain. The requested Vertiflex spacer is considered experimental in nature, as more research is needed to show its efficacy. The services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex spacer for the enrollee.