Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes provided to the enrollee on January 18, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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 99239 is not supported in the medical record. Specifically, the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed. A documented duration of time of 31 minutes or more is required to support this code. Therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. 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 for hospital discharge day management; more than 30 minutes provided to the enrollee on January 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on December 13, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 drug testing provided on December 13, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on November 17, 2019 from a non-contracted provider.
You asked the Plan to pay for the hearing aids. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you do not have out-of-network benefits.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. Review of the file show that you purchased hearing aids on November 17, 2019 from a non-contracted provider. Your EOC clearly states coverage for hearing aids is limited to the network hearing aid provider. Therefore, we decided that the Plan does not have to pay for hearing aids purchased on November 17, 2019 from a non-contracted provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic eye examination provided on November 5, 2019 by an in-network provider.
You asked the Plan to waive the copayment for the diagnostic eye examination. You say that you believe the providers are network providers. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a diagnostic eye examination provided on November 5, 2019 by an in-network provider. You are asked to pay a $40 copayment for the vision care 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 diagnostic eye examination provided on November 5, 2019 by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses provided on December 12, 2019.
You asked the Plan to pay for the eyeglasses. You say that you were told by two different parties, including the Plan, that you still had $90 left in your reimbursement allowance. The Plan denied your request. The Plan says you have already received the maximum amount of coverage allowed for this type of service.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. We looked at the file and the Plan's rules. The Plan paid $250 for your non-Medicare covered eyewear. You have exhausted the maximum benefit for the plan year. Therefore, we decided that the Plan does not have to pay for the eyeglasses provided on December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3000) provided on October 31, 2019.
You asked the Plan to pay for foot orthotics. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3000) provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for humidifier, heated, used with positive airway pressure device (E0562RR) and respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) (E0470RR) provided from August 15, 2019 through November 15, 2019.
You asked the Plan to waive the copayment for the DME. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says they have agreed to reprocess the claim to pay the out-of-network Medicare allowed 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). Review of the file show that you received DME provided from August 15, 2019 through November 15, 2019. The Plan processed the claim with your out-of-network benefits and you owe 20% coinsurance for the out-of-network DME. Therefore, the Plan will not fully reimburse you for the DME. 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 humidifier, heated, used with positive airway pressure device (E0562RR) and respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) (E0470RR) provided from August 15, 2019 through November 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral custom foot orthotics (L3000).
You asked the Plan to pre-approve custom foot orthotics. You say that you are requesting a reconsideration of the Plan's denial as custom foot orthotics are medically necessary. The Plan denied your request. The Plan says that custom foot orthotics are not a covered benefit under your contractual policy for your condition.
Medicare rules state that supportive devices for the feet (such as custom foot orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although custom foot orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of custom foot orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve bilateral custom foot orthotics (L3000).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 3, 2019 through December 4, 2019.
You asked the Plan to pay for acute inpatient hospital 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 hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 3, 2019 through December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for AirHawk Lightweight Folding Electric Wheelchair provided on June 21, 2019.
You asked the Plan to pay for the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 DME have not been met. We reviewed your records and they show that you have osteoarthritis, hypertension and heart disease. You currently walk with a cane. There is no face to face evaluation indicating the member's ability to use the chair was appropriate for safe operation such that "The beneficiary has the mental and physical capabilities to safely operate the power wheelchair" and there is no home study indicating that "The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair" Your condition doesn't meet the rules for approval because the required criteria for safe operation within the home is not provided. In addition, your request does not meet the conditions for approval because the Airhawk Lightweight Folding Electric Wheelchair has additional features that exceed your need because they are designed for use outside the home. Additionally, this supplier of this device has stated that they do not participate with Medicare. Therefore, we decided that the Plan does not have to pay for AirHawk Lightweight Folding Electric Wheelchair provided on June 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 7, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 7, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of aflibercept.
You asked the Plan to pre-approve aflibercept. You say that the enrollee needs this drug, and you do not agree with the Plan's frequency recommendation. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because this request exceeds the approved frequency based on Food & Drug Administration (FDA) guidelines.
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 aflibercept. Our reviewer says that the enrollee meets the Medicare criteria for use of aflibercept. Our physician reviewer found the enrollee has active neovascular age-related macular degeneration (AMD) in the eye as seen by the macular subretinal hemorrhage and cystic changes. Therefore, it would be medically reasonable and necessary to treat this enrollee with an intravitreal anti-vascular endothelial growth factor (anti-vegF) injection such as aflibercept. Given that the enrollee has a history of neovascular AMD and has no documented history of poor response to anti-vegF agents, it is reasonable to conclude that aflibercept is safe and effective to treat this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of aflibercept have been met. Therefore, we decided that the Plan has to pre-approve use of aflibercept.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for bilateral foot inserts (L3000) provided to the enrollee on August 21, 2019.. You say that the claim should be paid. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for X-rays (72081) provided June 6, 2019 to December 31, 2019.
You asked the Plan to pay for the x-rays. You say that the x-rays should be covered. The Plan denied your request. The Plan says the x-rays are not a covered chiropractic service.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the x-rays have not been met. Therefore, we decided that the Plan does not have to pay for X-rays (72081) provided June 6, 2019 to December 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 36 additional routine transportation trips (A0120).
You asked the Plan to pre-approve 36 additional routine transportation trips. You say that you need the additional routine transportation trips. The Plan denied your request. The Plan says the requested services exceed the benefit allowance. Therefore, coverage criteria has not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 36 additional routine transportation trips (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (TOF - testing to monitor the depth of muscle relaxation during surgery - coded as 95999 - Unlisted neurological or neuromuscular diagnostic procedure) provided to the enrollee on January 10, 2019.
You asked the Plan to pay for the 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. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. We reviewed your records and they show that you had spinal surgery. The record sent by your provider indicates that you underwent back surgery requiring neurophysiology monitoring. Other neuromonitoring services have been approved for payment by the Plan. Medicare guidelines say that this item or service is considered a bundled procedure as the cost is included in the cost of the primary procedure. Under Medicare guidelines, your request is not a covered benefit because Medicare does not make separate payment for this service. Therefore, we decided that the Plan does not have to pay for train of four testing (TOF - testing to monitor the depth of muscle relaxation during surgery - coded as 95999 - Unlisted neurological or neuromuscular diagnostic procedure) provided to the enrollee on January 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar sacral-orthosis (L0648) provided to the enrollee on September 12, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the durable medical equipment is not medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of a credible physical examination of the back. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for lumbar sacral-orthosis (L0648) provided to the enrollee on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on December 20, 2018.
You asked the Plan to waive the copayment for urgent care visit. You say that you were sick while out of the state on vacation. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $30 copayment for urgent care visit. You have been asked to pay $30 copayment for urgent care visit. Urgent care visit falls within the Urgently Needed 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 urgent care visit provided on December 20, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom shoes (A5500) and inserts (A5512).
You asked the Plan to pre-approve custom shoes and inserts. You say that you are requesting a reconsideration of the Plan's denial as you are a Type 2 diabetic and have been approved for custom shoes and inserts by the health plan in previous years. The Plan denied your request. The Plan says that custom shoes and inserts are not a covered benefit under your contractual policy for your condition.
Medicare rules state that supportive devices for the feet (such as custom shoes and inserts) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you have been diagnosed with Type 2 diabetes; however, the documentation does not show that you have evidence of diabetic foot disease, or any prior history of such. Although custom shoes and inserts may be appropriate for you, neither Medicare nor the Plan provides coverage of custom shoes and inserts for your condition. Therefore, we decided that the Plan does not have to pre-approve custom shoes (A5500) and inserts (A5512).