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

We decided that the Plan does not have to pay forwrist hand orthosis provided on January 12, 2018 by an out of network (OON) provider.You asked the Plan to pay forthe orthosis. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says enrollee's must receivetheir medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 forwrist hand orthosis provided on January 12, 2018 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 26, 2019.
You asked the Plan to pay for the dental service. You say that the provider is still contracted with your plan. The Plan denied your request. The Plan says limited oral exams are covered once per patient, per provider. The Plan also says that the benefit limit has been exhausted.
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 and limited oral evaluations are a covered service, the benefit limit has been exhausted. The record shows that the Plan previously paid for a limited oral exam from this provider that you received on November 28, 2019. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forPost-stabilization inpatient care provided September 1 to September 2, 2019.You asked the Plan to pay forthe Post-stabilization inpatient care. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee was stable for transfer to a plan facility.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 Post-stabilization inpatient care. Our reviewer says that coverage criteria for services rendered after 10:00 a.m. on September 1, 2019 have not been met. Our physician reviewer found the review indicates that as of 10:00 a.m. on 9/1/19, the enrollee was hemodynamically and neurologically stable for ambulance transport with monitoring to the nearest Plan facility. By this time, the enrollee was no longer on IV drip and had been cleared for transfer by Cardiology. The enrollee was alert and oriented, had a heart rate in the 50s, and had an improved sodium level. All lab test results, and diagnostic imaging have confirmed that the enrollee's emergency medical condition had stabilized.We lookedat this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Post-stabilization inpatient care. have not been met.Therefore, we decided that the Plan does not have to pay forPost-stabilization inpatient care provided September 1 to September 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code L29999.
You asked the Plan to pre-approve the compression stockings. You say that the enrollee requires the stockings. The Plan denied your request. The Plan says the compression stockings are non-covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code L29999 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code L29999.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex procedure).
You asked the Plan to pre-approve Vertiflex procedure. You say that the enrollee would benefit from a less invasive approach offered by Vertiflex as compared to a more invasive laminectomy procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is contraindicated for the enrollee and is considered to be experimental/investigational.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has significant scoliosis and therefore this procedure is contraindicated. Also, the literature reports on a single level of insertion, not 2 levels. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex procedure).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 22,
2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says
there is no valid referral for these services.
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
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you no longer require daily skilled therapy or nursing.
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. Continued SNF services beyond March 26, 2020 were requested. 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 services. Our physician reviewer found that from a nursing perspective, you have stable vital signs, and were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a total assist level with transfers. You require varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled services on a daily basis. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe paramedic intercept services (A0432) provided August 8, 2019.You asked the Plan to pay forthe paramedic intercept services. You say that you have taken an ambulancein the past and it was always billed as one service. You have never heard of being billed separately and do not feel that you owe two different bills.The Plan denied your request. The Plan says this service is not covered.The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS) volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that does not have a contract with the volunteer ambulance company that provided the transport services.Therefore, we decided that the Plan does not have to pay forthe paramedic intercept services (A0432) provided August 8, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Inpatient Hospital services provided
August 13 to August 15, 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 cost-sharing 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 $300
copayment per admission for Inpatient Hospital Care, with a maximum of $900 per calendar year.
You have been asked to pay a $300 copayment for an inpatient admission. This 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 Inpatient Hospital services
provided August 13 to August 15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October 1, 2019 to October 30, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services. The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October 1, 2019 to October 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower copayment for Levalbuterol nebulizer solution.
You asked the Plan to pre-approve the lower copayment. You say that you have been stable on this medication for years. The Plan denied your request. The Plan says Part B Drugs are not eligible for tier cost exceptions.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lower copayment have not been met. Specifically, this medication is covered under Medicare Part B. Part B drugs are not eligible for tier cost exceptions. Therefore, we decided that the Plan does not have to pre-approve a lower copayment for Levalbuterol nebulizer solution.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on October 21, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says prior authorization is required for services provided by non-participating providers.
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 nurse practitioner services provided on October 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper partial denture, cast metal, resin base (D5213) provided on September 16, 2019.
You asked the Plan to pay for the dental item. You say that the enrollee is on a fixed income. You say that the enrollee needed dental work done because he was having trouble eating. You also say the enrollee was not aware that the services would not be covered. The Plan denied your request. The Plan says partial dentures are not a covered service.
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 upper partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the upper partial denture, cast metal, resin base (D5213) provided on September 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Creon for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee has been on this with good control of symptoms. The Plan denied your request. The Plan says that this is not covered under 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 Creon 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, the wellness visit, the smoking and tobacco use cessation counseling visit, the pneumococcal polysaccharide vaccine, and the administration of the vaccine provided on September 18, 2019.
You asked the Plan to pay for the physician services. You say that the enrollee was discharged from hospice on September 13, 2019. You say that the enrollee was advised he needed to see his doctor. You say that the enrollee was seen on September 18, 2019. You also say that the enrollee re-enrolled in hospice on October 10, 2019. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on September 13, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the office visit, the wellness visit, the smoking and tobacco use cessation counseling visit, the pneumococcal polysaccharide vaccine, and the administration of the vaccine provided on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered to the enrollee on September 16, 2019.
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 procedure code 99152 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 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes. We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. 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 moderate sedation services rendered to the enrollee on September 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean expandable control system for S. Woodson's power wheelchair.You asked the Plan to pre-approvean expandable control system. The Plan denied your request. The Plan says there is no medical need to control the approved power options through a joystick. The enrollee's upper limb strength is adequate to control the power options using their own switches.The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications. 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 an expandable control system. Our physician reviewer foundthat the documentation does not reveal the enrolleerequires a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non-proportional input device such as sip and puff, or the need to control 3 or more power seating actuators through the drive control. The enrollee'sstrength and ability to be independent with eating is sufficient to control the power options with their separate switches already included with the approval of these power options.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable control system have not been met.Therefore, we decided that the Plan does not have to pre-approvean expandable control system for power wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on December 3, 2018 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that your doctor provided medically necessary services to the enrollee in good faith and in consideration for the services rendered your doctor is seeking reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 subsequent nursing facility care (99309) provided on December 3, 2018 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower 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 pre-approve SNF services. Our physician reviewer found that from a nursing perspective, the enrollee has stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is ambulatory with no assist device independently. She declined occupational therapy services. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis.We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services