Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on June 8, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 had network providers available who could have provided 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 forphysician services provided on June 8, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotics provided on July 15, 2020.
You asked the Plan to pay for the foot inserts (L3000). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the foot inserts were billed with an incorrect place of service.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The orthotics were billed with place of service 11 (office), not where the item is being used. Therefore, we decided that the Plan does not have to pay for orthotics provided on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on September 23, 2020, by an out-of-network provider.You asked the Plan to pay forthe office visit. You say that you never had to pay this provider before.The Plan denied your request. The Plan says you did not request prior authorization for the out of network 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 had network providers available who could have provided 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 forthese items/services.Therefore, we decided that the Plan does not have to pay forthe office visit provided on September 23, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on May 5, 2020. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 had network providers
available who could have provided the services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on May 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on June 9, 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 claim was billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on June 9, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a commode chair.
You asked the Plan to pre-approve a commode chair. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a commode chair is only covered for certain
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 a commode chair. Our reviewer says
that the documentation does not support that the requested item is medically reasonable or necessary. Our
physician reviewer found that you have a history of unstable gait and falls. Based on the medical records
provided there is no documentation that you are physically incapable of utilizing regular toilet facilities. The
records indicate that you are independent with toileting. The documentation does not support that you are
confined to a single room or that you are confined to one level of the home environment and there is no toilet
on that level or that the enrollee is confined to the home and there are no toilet facilities in the home. Therefore,
you do not meet criteria for the requested commode.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a commode chair have not been met. Therefore, we decided that the Plan does
not have to pre-approve a commode chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.

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 had network providers available who could have provided the services at issue in this appeal. 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 forthe medical services provided to the enrollee by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveSynvisc-One for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysstep therapy exception criteria has not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc.  Step therapy, as outlined by the plan, requires this be trialed first. The documentation does not outline contraindications or reasons this medication was not considered or that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Synvisc-One is not approved as step criteria have not been met.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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approveSynvisc-One for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on
August 3, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you cannot afford the
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being
charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You received a Medicare Part B drug on August 3, 2020. The allowed amount is $1,194 and 20% of that is
$238.80.
You have been asked to pay the total coinsurance amount of $238.80 for a Medicare Part B drug. A Medicare
Part B drug 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 coinsurance for a Medicare Part B drug provided on August 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora fully hospital bed with mattress (E0255)You asked the Plan to pay fora fully electric hospital bed. You say that an order was written for a hospital bed on June 16, 2020 with errors by the provider. Another order was written on August 11, 2020 but you were not made aware of this hold up. You needed the bed that you believed was purchased through the correct provider. You cannot return the bed.The Plan denied your request. The Plan says Medicare rules say that health plans can require enrollees to get care from network providers with prior authorization, this had neither.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. Regardless of the network status or theprior authorization situation, which did have extenuating circumstances, a total electric hospital bed is never covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pay fora fully hospital bed with mattress (E0255)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient rehabilitation facility (IRF) services provided on January 15, 2020, to February 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for IRF services. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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 had network providers available who could have provided 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 inpatient rehabilitation facility (IRF) services provided on January 15, 2020, to February 7, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for X-rays provided on August 31, 2020, and September 15, 2020. You asked the Plan to waive the copayments for X-rays. You say that you received the X-rays at the physician's office and cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment for X-rays provided in a physician's office and a $50 copayment when provided in an outpatient hospital facility.
The record shows that you received an X-ray at an outpatient hospital facility on August 31, 2020. Therefore, you are responsible to pay the $50 copayment. The record shows that you received an X-ray at an outpatient hospital facility on September 15, 2020. Therefore, you are responsible to pay the $50 copayment. The total amount you owe is: $100. You have been asked to pay the total copayment amount of $100 for X-rays. X-rays fall within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for X-rays provided on August 31, 2020, and September 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentsfor the diverticulectomy (43130), and the esophagoscopy (43191) provided from October 22, 2019, through October 23, 2019.You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copaymentshavebeen applied correctly to the services provided.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 $250 copayment per visit for in-network Medicare-covered outpatient surgical services. Additionally, you must pay a $40 copayment for each in-network specialist visit for Medicare-covered benefits. You have been asked to pay $290 ($250 copay + $40 copay) for the outpatient surgery and specialist visit provided. 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 copaymentsfor the diverticulectomy (43130), and the esophagoscopy (43191) provided from October 22, 2019, through October 23, 2019.Your complaint that you had complications after surgery and were referred to another doctor for further careis not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesemi-electric hospital bed (E0260) and bedside rails, half length (E0305).You asked the Plan to pre-approvethe semi-electric hospital bed and bedside rails. You say that the enrollee has left side paralysis and without the bed the cannot get out of bed to provide self needs. Caregiver's have trouble getting the enrollee out of bed.The Plan denied your request. The Plan says the hospital bed is not medically necessary for the enrollee's condition.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 semi-electric hospital bed and bedside rails. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there isno documentation that the enrollee's condition requires positioning of the body in ways not feasible in an ordinary bed. There is no documentation that the enrollee requires frequent changes in body position or immediate changes in body position. There isno documentation that the enrollee's condition requires special attachments that cannot be fixed and used on an ordinary bed. There is no documentation that a semi-electric hospital bed is medically necessary for this enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the semi-electric hospital bed and bedside rails have not been met.Therefore, we decided that the Plan does not have to pre-approvesemi-electric hospital bed (E0260) and bedside rails, half length (E0305).
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 these services are medically necessary. The Plan
denied your request. The Plan says that you are able to get the necessary rehabilitation, such as physical
therapy and occupational therapy at the skilled nursing level of care with the goal of safely returning home.
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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You reside in an assisted living facility where you are
being treated for a urinary tract infection. You have weakness attributed to disuse myopathy. Your medical
conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing
or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation
program.
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition
does not meet Medicare criteria for IRF care.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 27, 2020.
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 15004 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 15004 is surgical preparation or creation of recipient site
by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar
contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100
sq cm or 1% of body area of infants and children.
We find that CPT code 15004 is not supported in the medical record. Specifically, there is no documentation of
surgical preparation or creation of recipient site by excision of open wounds. 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 surgical services rendered on February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe IV tubing extension set and infection control supplies provided during a procedure on August 27. 2020 billed with codes S1015 and S8301.You asked the Plan to pay forthe IV tubing and infection control supplies. You say that these services should be paid.The Plan denied your request. The Plan says the appealed codes were paid aside from the S-codes which are not valid for Medicare billing.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 thatCPT codes S1015 and S8301 not supported. Specifically, these codes havea status indicator of "I" in the Physician Fee Schedule meaning that they are invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the IV tubing and infection control supplies have not been met.Therefore, we decided that the Plan does not have to pay forthe IV tubing extension set and infection control supplies provided during a procedure on August 27. 2020 billed with codes S1015 and S8301.