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

We decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment),
with any type side rails, with mattress (E0260).
You asked the Plan to pre-approve the hospital bed. 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 hospital bed have not been met. Medicare covers this special
bed when the member needs to change position very often, use traction, or raise the head of the bed more than
30 degrees due to heart and lung problems. The facts sent by your doctor do not show that you have any of
those conditions. You do not meet the Medicare guidelines. Therefore, we decided that the Plan does not have
to pre-approve hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress
(E0260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for addition to lower extremity orthosis, knee control, condylar
pad (L2810), bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee.
You asked the Plan to pay for the foot orthotics. You say that the claim should be paid. The Plan denied your
request. The Plan says the services are not supported by the records.
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 foot orthotics. Our reviewer says that the
enrollee does not meet criteria for the orthoses and sleeves ordered. Our physician reviewer found the
documentation in the case file does not support that the requested knee orthoses with sleeves were medically
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the
LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's
knees, and there is no objective documentation of joint laxity. The items coded L2397 (sleeve) and L2810
(condylar pad) are not separately payable when the base item is not covered.
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 foot orthotics have not been met. Therefore, we decided that the Plan does
not have to pay for addition to lower extremity orthosis, knee control, condylar pad (L2810), bilateral knee
orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe nebulizer provided on January 18, 2020.You asked the Plan to waive the coinsurance forthe DME. 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 show that you received the nebulizer provided on January 18, 2020. Your EOC states, enrollees must pay 20% coinsurance for DME and related supplies. Therefore, you are asked to pay 20% coinsurance for the nebulizer. 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 doesnot have to waive the coinsurance forthe nebulizer provided on January 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from October 9, 2019 through November 7, 2019.You asked the Plan to pay for SNF 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from October 9, 2019 through November 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral antibiotics and oral Methylprednisolone provided on November 23, 2019.
You asked the Plan to pay for the oral antibiotics and oral Methylprednisolone. You say that you had a painful throat and difficulty swallowing due to acute tonsillitis. The Plan denied your request. The Plan says these drugs are not Part B covered and are not covered under your 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 pay for the oral antibiotics and oral Methylprednisolone provided on November 23, 2019.
Benefits for the oral antibiotics and oral Methylprednisolone 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy services (S9328) provided from August 24, 2019 to August 31, 2019.You asked the Plan to pay forthe home infusion therapy services. 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 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 rulesfor coverage of the home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy services (S9328) provided from August 24, 2019 to August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the certolizumab pegol injection and
chemotherapy administration provided on January 10, 2020.
You asked the Plan to waive the coinsurance for the certolizumab pegol injection and chemotherapy
administration. You say that you cannot stop taking this medication. You say that you don't have the resources
to pay. 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 20%
coinsurance for each Medicare-covered Part B drug. Additionally, for the administration of that drug, you will
pay the cost-sharing that applies to primary care provider services, specialist services, or outpatient hospital
services (as described under "Physician/Practitioner Services, Including Doctor's Office Visits" or "Outpatient
Hospital Services" in this benefit chart) depending on where you received drug administration or infusion
services. You have been asked to pay $687.32 for the certolizumab pegol injection and chemotherapy administration. The certolizumab pegol injection and chemotherapy administration fall within the "Medicare Part B
Prescription Drugs" benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the certolizumab
pegol injection and chemotherapy administration provided on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision care services provided to the enrollee.
You asked the Plan to pay for vision care services. You say that the services are medically necessary. The Plan denied your request. The Plan says the non-urgent services are not authorized because the provider is a non-network provider who does not work with the health plan and the member self-referred for services. The Plan states the primary care provider did not refer the member. The plan states they require utilization of network providers when possible and available, and requires authorization for certain services. The Plan states no medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented and there is an on-line Medicare site to verify eligibility. The Plan states there is no network deficiency for these services and alternate network providers were found.
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 vision care services provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.
You asked the Plan to pay for the services. 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.
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. We looked at the file and the Plan's rules. Your EOC states. $40 copayment for each visit to a specialist, such as optometrist for Medicare-covered benefits. The provider did charge the incorrect copay amount of $45 and your account reflects a $5.00 credit. In addition, you received a non-routine eye-refraction test in the amount of $25. A routine eye refraction is only covered when services received by an in network provider with the supplemental vision plan, your eye care network. This service was not routine as you had a pre-existing medical condition (Type 2 Diabetes). Therefore, we decided that the Plan does not have to pay for the services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 3, 2020.You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the provider has opted out of the Medicare program and is not eligible for payment.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by OON provider. This provider has opted out of the Medicare program. The file shows that OON provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay for the physician services provided on January 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Ambulance Transport (A0429) provided November 6, 2019.You asked the Plan to waive the copayment for the Ambulance Transport. 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 $350 copayment for Ambulance Services. You have been asked to pay a $350 copayment for the Ambulance Transport. The Ambulance Transport falls within the Ambulance 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 Ambulance Transport (A0429) provided November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for a therapeutic continuous glucose monitor provided on August 7, 2019.
You asked the Plan to pay for the supply allowance (K0553). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the medical records and physician order appear to be altered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The documentation submitted did not indicate the provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the supply allowance (K0553) have not been met. Therefore, we decided that the Plan does not have to pay for the supply allowance for a therapeutic continuous glucose monitor provided on August 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided November 12, 2019.
You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim was submitted incorrectly.
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 71045 is not supported in the medical record. Specifically, the service was submitted as a screening service, but the claim was submitted with an improper setting (Emergency Room) for this type of service. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic limb compression device (E0651) and garment (E0667) provided July 1, 2019. You asked the Plan to pay for pneumatic limb compression device and garment. You say that you have attached all the supporting documentation. Please reprocess the claim. The Plan denied your request. The Plan says the records provided do not support the service billed. The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 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 pneumatic limb compression device and garment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have attended a follow-up appointment for right lower extremity cellulitis. At the appointment, the cellulitis appeared to be resolved, but bilateral lower extremity lymphedema and chronic stasis skin changes were noted. The plan was to provide compression stockings and elevation. There is no documentation of a plan for pneumatic compression devices. It is possible that the pneumatic compression devices were ordered by the enrollee's wound clinic, from which no records have been received for review. The documentation does not support the medical necessity or reasonableness of the supplied service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pneumatic limb compression device and garment have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic limb compression device (E0651) and garment (E0667) provided July 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forextraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on December 10, 2019.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.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.You exhausted your $1,000 maximum benefit allowance. Your EOC states, your Annual Maximum is $1,000 (After the annual maximum is exhausted, any remaining charges are your responsibility).Therefore, we decided that the Plan does not have to pay forextraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the arthrocentesis and hyaluronan injection provided.
You asked the Plan to waive the cost share for the arthrocentesis and hyaluronan injection. You say that the doctor never informed you of the amount you would be billed. You say that you cannot afford the bill. The Plan denied your request. The Plan says the cost share 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 $45 copayment for services obtained from an in-network specialist and 20% coinsurance for each in-network, Medicare-covered Part B drug.
You have been asked to pay a total of $725.82 for the arthrocentesis and hyaluronan injection.
Service
Allowed Amount
Standard Cost
Member Liability
Arthrocentesis
$110.51
$45
$45
Hyaluronan Injection
$984.68
20%
$196.94
Arthrocentesis
$110.51
$45
$45
Hyaluronan Injection
$984.68
20%
$196.94
Arthrocentesis
$110.51
$45
$45
Hyaluronan Injection
$984.68
20%
$196.94
TOTAL:
$725.82
The arthrocentesis falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The hyaluronan injection falls within the "Medicare Part B Prescription Drugs" 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 cost share for the arthrocentesis and hyaluronan injection provided.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that you were transported to the hospital and were admitted due to an ankle injury. You say that you believe you are being billed incorrectly. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on December 21, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on January 24, 2020.You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.Medicare rules say that plans can require enrollees to get care from network providers. Thecontract 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 hospital outpatient clinic visit provided on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea raised toilet seat and a bathtub seat.You asked the Plan to pre-approvea raised toilet seat and a bathtub seat. You say that the enrollee needs a raised toilet seat and a bathtub chairbecause of multiple health issues.The Plan denied your request. The Plan says these itemsarenot a covered benefit.The Plan must follow Medicare rules. Medicare rules say that raised toilet seats and shower chairs are not covered because they are not primarily medical in nature. While a raised toilet seatand a bathtub seat 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 pre-approvea raised toilet seat and a bathtub seat.