Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 2, 2019 to September 8, 2019.You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim includes the visit code S9121 which is not correct per Medicare guidelines. The appropriate G code was missing on the claim for the billed dates of service.Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 2, 2019 to September 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 15, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 15, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee did not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee did not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The skilled nursing or skilled therapy services (or a combination of these services) were not needed on a "daily basis" in a SNF. As a practical matter this enrollee did not require the necessary services on an inpatient basis, in a skilled nursing facilitysetting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.You asked the Plan topre-approve the compression stockings. You say that you need these for a history of deep venous thrombosis.The Plan denied your request. The Plan says his compression stocking is not a covered benefit under Medicare The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 A6530.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wireless capsule endoscopy.You asked the Plan to pre-approve wireless capsule endoscopy. 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. 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 wireless capsule endoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found wireless capsule endoscopy may be considered medically necessary and covered for the diagnosis of small bowel abnormalities when upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, or radiologic procedure during the period of illness has failed to identify the source of bleeding or abnormality. In the enrollee's case, both EGD and colonoscopy identified multiple abnormalities. While no active bleeding was seen, both the colonic angioectasias and upper GI portal hypertensive changes would be expected sources of chronic blood loss. As such, the medical necessity for wireless capsule endoscopy is not supported in this case by provided records.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wireless capsule endoscopy have not been met.Therefore, we decided that the Plan does not have to pre-approve wireless capsule endoscopy
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan eye drops.
You asked the Plan to pre-approve Zioptan. You say that the enrollee has tried and failed other medications. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug Plan.
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 Zioptan eye drops.
Benefits for Zioptan 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Victoza for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered by the Plan.
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 Victoza 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on October 8, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicarerules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decidedthat the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical eye examination provided on November 6, 2019.You asked the Plan to pay for the medical eye examination. The Plan denied your request. The Plan says this provider is not participating with the Plan for medical vision care.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 a medical eye examination provided on November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment codes that are additional to a knee brace (L2810, L2275, L2820, L2780, L2830).
You asked the Plan to pre-approve the durable medical equipment. You say that you have knee pain and an knee brace will aid in pain reduction. The Plan denied your request. The Plan says they agree that a knee orthosis with suspension sleeve (L1851, L2397), but the additional codes are not separately payable with the L1851 billed orthosis.
The Plan must follow Medicare rules. Medicare rules say that certain addition codes are not separately payable for knee orthoses. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve durable medical equipment codes that are additional to a knee brace (L2810, L2275, L2820, L2780, L2830).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and dental extraction with an oral surgeon.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says this is not covered when provided by an oral surgeon.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the services when the services are provided by participating general dentist.Dental services are not covered by your plan when they are provided by an oral surgeon. The services must be provided by a participating general dentist. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pre-approve a consultation and dental extraction with an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Starkey hearing aids for the enrollee.You asked the Plan to pre-approve the aids. You say that this is medically necessary, as you only stock Starkey.The Plan denied your request. The Plan says this specific brand of hearing aids is not covered.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. The Plan pays for hearing aids only when received from TruHearing.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 aids. Our reviewer says that  Our physician reviewer found The requested brand is not considered part of your hearing aid benefit. Based on this information, we decided that the Plan's rules for coverage of the aids have not been met.Therefore, we decided that the Plan does not have to pre-approve Starkey hearing aids for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D3330) provided on December 27, 2019.
You asked the Plan to pay for dental services (D3330). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 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 panoramic x-rays (D0330) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental services (D3330) provided on December 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two sleep studies. You asked the Plan to pre-approve the sleep studies. The Plan denied your request. The Plan says this is not medically necessary. The Plan follows Medicare rules. Medicare rules say that sleep testing is covered for the indications stated above. 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 sleep studies. Our reviewer says that the requested sleep studies are not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 57-year-old female with a history of GERD, obesity, schizophrenia, anxiety, fatty liver, insomnia. There is no documentation of snoring or witnessed apnea. The requested sleep studies are not medically reasonable and necessary according to the coverage criteria established in the LCD. 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 sleep studies have not been met. Therefore, we decided that the Plan does not have to pre-approve two sleep studies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no provider narrative in the submitted documentation; therefore, there is no documentation of a patient complaint, history of present illness, physical exam, differential diagnosis, or treatment plan related to the requested imaging. The MRI is not reasonable or medically necessary based on the submitted documentation. 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 magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair glide.
You asked the Plan to pay for a stair glide. You say that you had to move and needed to get a lift chair because there was a split entry. You say that the stair chair was necessary because you could not get up and down the stairs without it. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair glide.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit provided on November 1, 2019.You asked the Plan to waive the coinsurance for the office visit. You say that your physician is in-network. You say that the claim should be reprocessed.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 must pay 50% coinsurance for provider and professional services at an out-of-network PCP's office. You have been asked to pay $51.89, which is 50% of the allowed amount for the office visit. The allowed amount is $103.78 (50% x $103.78 = $51.89). The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is out-of-network. 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 forthe office visit provided on November 1, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee has had a visiting nursing
service evaluation and in-home physical therapy, but this process has failed to strengthen him enough to
prevent falls. You say that the enrollee has outstripped his family's ability to care for him at in his current state.
You say that the last statement from VNS is that the enrollee is not safe at home. The Plan denied your request.
The Plan says the enrollee does not have post-acute needs. The Plan says that the Medicare benefit does not
provide for daily skilled services in the case of the enrollee's set of circumstances.
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 the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely
and effectively provide medically necessary and reasonable treatment. The enrollee does not have a new
tracheostomy tube, new enteral feedings, complex wound care or other SNF level skilled nursing need. The
enrollee's functional tolerance does not require skilled therapy services with the specialized skill, knowledge
and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable
treatment in a SNF. The skilled nursing or skilled therapy services (or a combination of these services) are not
needed on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services
on 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 pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extractions (D7140 x6) provided on November 14, 2019.You asked the Plan to pay forthe extractions (D7140 x6). You say that the extractions were medically necessary. The Plan denied your request. The Plan says the benefit is 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, there is a benefit limit for the extractions. The plan clearly states that only two extraction procedures are covered every calendar year. The records show the Plan paid for two extractions procedures on November 14, 2019, which exhausted the benefit.Therefore, we decided that the Plan does not have to pay forthe extractions (D7140 x8) provided on November 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused oral evaluation (D0160) provided on December 3, 2019.
You asked the Plan to pay for the problem focused oral evaluation (D0160). You say that the provider's office confirmed that you would be covered by insurance when you scheduled the appointment. The Plan denied your request. The Plan says the service is not a covered benefit.
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 problem focused oral evaluation (D0160) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused oral evaluation (D0160) provided on December 3, 2019.