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

We decided that the Plan does not have to pay for an office visit (99211) and urinalysis (81000) provided on April 11, 2019.
You asked the Plan to pay for an office visit and urinalysis. You say that these services were not related to hospice. The Plan denied your request. The Plan says coverage of these services is the responsibility of Original Medicare.
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Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.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 April 9, 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 an office visit (99211) and urinalysis (81000) provided on April 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on January 15, 2020.
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 lumbar-sacral orthosis (L0650) provided to the enrollee on January 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventative vitamin assay and metabolic function (82306) test provided on January 14, 2020. You asked the Plan to pay for the preventative vitamin assay and metabolic function (82306) test. 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. 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 test at issue in this appeal, the preventative vitamin assay and metabolic function (82306), 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 preventative vitamin assay and metabolic function (82306) test provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional mileage for routine transportation.
You asked the Plan to provide coverage for the additional mileage for routine transportation. You say that your doctor wants you to see a neuromuscular doctor, which is a 440 mile round way trip. The Plan denied your request. The Plan says the benefit only allows each one-way trip that does not exceed 50 miles.
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. We looked at your request, the records in the case file, and the rules. The file shows you are requesting an additional 440 miles. The Plan benefit only allows coverage of 50 miles for each one-way trip. Therefore, we decided that the Plan does not have to provide coverage for additional mileage for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermatology services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve dermatology services. You say that you would like to continue to see this provider.The Plan denied your request. The Plan says these services can be provided in-network.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve dermatology services to be provided by an out of network (OON) provider. Please contact the Plan for a list of approved in-network providers.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance forthe IV infusion. We decided that the Plan does not have to waivethe coinsurance forthe Part B drugs. You asked the Plan to reduce the coinsurance forthe IV infusion and Part B drugs. You say that you should only be charged a$95 copayment for the infusion.The Plan says that you have been charged the correct cost sharing amount. We decided that the Planhas to waivethe coinsurance forthe IV infusion. The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that you were charged for code 96365 which is considered a professional service for the administration of the IV infusion. The Plan says that you must pay a coinsurance amount of $31.95 for the IV infusion. Based on the plan contract, however, you cannot be asked to pay more than a $0 copayment for the IV infusion. Therefore, we decided that the Plan has to reduce the cost share for the IV infusion from a coinsurance amount of $31.95 to a $0 copayment. We also decided that the Plandoes not have to waivethe coinsurance forthe Part B drugs.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 Part B drugs.Therefore, we decided that the Plan does not have to reduce the coinsurance forthe Part B drugs.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injections (62321) to be provided by an out of network (OON) provider.You asked the Plan to pre-approve epidural steroid injections provided by an OON provider. You say that you do not trust another provider to give these injections.The Plan denied your request. The Plan says there are in-network providers that are able to provide this service. Therefore, coverage criteria has not been met.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve epidural steroid injections (62321) to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyvanse 30mg capsules.You asked the Plan to pre-approve Vyvanse 30mg capsules. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.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 Vyvanse 30mg capsules.Benefits for Vyvanse 30mg capsules 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 8, 2019 through December 9, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.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 shows that you were admitted on December 8, 2019 and discharged on December 9, 2019. You were asked to pay a $285 copayment for December 8, 2019, day 1 of your inpatient hospital care. You were discharged on December 9, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $285 copayment per day required for days 1-7. 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 care from December 8, 2019 through December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery provided on December 2, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for an outpatient surgery. You say that you would like this appeal reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an outpatient surgery provided on December 2,
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 22, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you weren't asked for payment at the visit. You say that you shouldn't have to pay. 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 $15 copayment for each in-network specialist visit for Medicare-covered benefits. You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 office visit provided on November 22, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided (92133, 92083) on August 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for the ophthalmology services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.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 nota 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 ophthalmology services provided (92133, 92083) on August 9, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen/pelvis.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 CT scans 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 the enrollee had an abdomen ultrasound on January 24, 2018 that revealed a liver with slight granular echogenicity, previous cholecystectomy, hysterectomy with left oophorectomy and a right ovarian cyst. There is no documentation of any symptoms or signs such as abdominal pain, abnormal exam findings, or abnormal x-ray or ultrasound findings to support the medical necessity of the requested CT scan.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 computed tomography (CT) scan of the abdomen/pelvis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit, health risk assessment and depression screening provided on October 9, 2019. You asked the Plan to waive the coinsurance for the office visit, health risk assessment and depression screening. You say that the doctor is in-network. You say that you do not agree with the out-of-network copayment. 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 40% coinsurance for provider and professional services at an out-of-network PCP's office and 40% coinsurance for a depression screening at an out-of-network PCP's office. You have been asked to pay a total of $51.25 for the office visit, health risk assessment and depression screening. The office visit and health risk assessment fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The depression screening falls within the "Depression screening" 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 for the office visit, health risk assessment and depression screening provided on October 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered from January 22, 2020 to January 28, 2020.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 infusion therapy rendered from January 22, 2020 to January 28, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglass lens upgrades you received on December 13,
2019.
You asked the Plan to pay for the lens upgrades. The Plan denied your request. The Plan says these services are
not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers one pair of standard eyeglasses.
We looked at the file and the Plan's rules. The plan covers one pair of standard eyeglasses. The requested lens
upgrades are not covered under your plan. Based on this information, we decided that the Plan's rules for
coverage of the lens upgrades have not been met. Therefore, we decided that the Plan does not have to pay for
the eyeglass lens upgrades you received on December 13, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve Cyclobenzaprine 10 MG Tablet.You asked the Planto pre-approvethe drugs. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee has a medical only policy with the plan.The Plan must follow Medicare rules. The rulessay 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 Plandoes not haveto pre-approveCyclobenzaprine 10 MG Tablet.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on October 31, 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 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 testing services rendered on October 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee required minimal assistance with toileting. The enrollee required moderate independence with grooming. The enrollee required supervision for eating, transfers, and walking. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical conditions are chronic and her medical status does not require an IRF admission or intensive physician or nursing supervision in an IRF. The enrollee may benefit from physical therapy and occupational therapy but the documentation does not indicate that the patient's functional level requires this on an intensive level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the tracheostomy shower protector (A7523).
You asked the Plan to pre-approve the tracheostomy shower protector. You say that this is medically necessary to save you from aspirating water and drowning The Plan denied your request. The Plan says this is considered a convenience item and is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the tracheostomy shower protector (A7523).