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

We decided that the Plan has to pre-approve a therapeutic SI block.
You asked the Plan to pre-approve the therapeutic SI block. You say that the SI block is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says that the notes do not indicate member had at least 75% less pain after last shot or how the shots made what member does easier.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the therapeutic SI block. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the member had a successful prior diagnostic block. 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 therapeutic SI block have been met. Therefore, we decided that the Plan has to pre-approve a therapeutic SI block.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopy provided on April 17, 2019.
You asked the Plan to pay for the surgical service. You say that the service provided to the enrollee was emergent. You also say that you submitted the claim to the hospice provider and the claim was denied stating the services were not related to the enrollee's hospice diagnosis. The Plan denied your request. The Plan says during the election, fee-for-service Medicare covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laparoscopy provided on April 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a non-covered POV (K0899) purchased from an out-of-network, non-contracted vendor, on June 22, 2019.
You asked the Plan to pay for the POV. You say that you purchased the POV on your own without prior referral or authorization because you wanted it right away. The Plan denied your request. The Plan says they have no contractual obligation to cover a non-covered item, nor one purchased without prior referral or authorization, nor from an out-of-network, non-contracted vendor.
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. You purchased a DME item that is not covered by Medicare (K0899). As such, this item would never be covered. In addition, you bought the item from an out-of-network, non-contracted vendor, without prior referral or authorization from Plan. Therefore, we decided that the Plan does not have to pay for a non-covered POV (K0899) purchased from an out-of-network, non-contracted vendor, on June 22, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the enteral formula and enteral feeding supply kit provided from October 23, 2019 to November 5, 2019 and from November 6, 2019 to November 14, 2019.
You asked the Plan to pay for the enteral formula and enteral feeding supply kit. You say that these items have been paid by Medicare in the past. You also say that the physician and the facility are in-network. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the enteral formula and enteral feeding supply kit provided from October 23, 2019 to November 5, 2019 and from November 6, 2019 to November 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for seat lift mechanism (CPT Code E0627) and sales tax purchased from a non-certified Medicare provider on March 28, 2019.
You asked the Plan to pay for the DME. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says Turner Furniture is not a Medicare enrolled provider and as such is not eligible for reimbursement from Medicare for services rendered. The Plan states you purchased the chair before the order was requested.
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. Turner Furniture is not certified with Medicare and the Plan cannot pay a provider who is not eligible to participate in Medicare. Therefore, we decided that the Plan does not have to pay for seat lift mechanism (CPT Code E0627) and sales tax purchased from a non-certified Medicare provider on March 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing care provided on July 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 skilled nursing care provided on July 29, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 2, 2018 to September 8, 2018 by an OON provider.
You asked the Plan to pay for the skilled nursing services. You say that the enrollee required increased care due to medication changes and decreased balance. You also say that the enrollee needed assistance with activities of daily living due to decreased balance and safety awareness. The Plan denied your request. The Plan says the provider never contacted the Plan to verify insurance, current eligibility, or authorization requirements. The Plan also says that the provider failed to request prior authorization before rendering the services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 skilled nursing services provided from September 2, 2018 to September 8, 2018 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Transcutaneous Electrical Nerve Stimulator provided on September 19, 2018.
You asked the Plan to pay for the Transcutaneous Electrical Nerve Stimulator (E0730). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the claim was submitted untimely without the correct modifier.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.
The record shows that a claim for the Transcutaneous Electrical Nerve Stimulator (E0730) was not filed until October 24, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. The claim is missing a modifier. Therefore, we decided that the Plan does not have to pay for the Transcutaneous Electrical Nerve Stimulator provided on September 19, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture and mandibular partial
denture.
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. You say that you lost your
original dentures while traveling in 2017. You also say that you cannot chew food and only have teeth in the
front. The Plan denied your request. The Plan says these services exceed the 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, dentures are limited to one set every 5
years. The record shows that you received a maxillary partial denture and a mandibular partial denture on
September 20, 2016 and your dentures benefit is now exhausted. Therefore, we decided that the Plan does not
have to pre-approve a maxillary partial denture and mandibular partial denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on February 8, 2019.
You asked the Plan to pay for the train of four testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says train of four is considered integral to the primary procedure and therefore is part of a bundled payment.
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 95999 is not supported in the record. Specifically, train of four monitoring is considered integral to the primary neurophysiology monitoring and is therefore part of a bundled payment. Based on this information, we decided that Medicare rules for coverage of the train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on February 8, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve porcelain retainer crowns for tooth #'s 8 and 10 and a pontic for tooth #9.
You asked the Plan to pre-approve the retainer crowns and pontic. You say that you would like a bridge. The Plan denied your request. The Plan says that you cannot be missing any of your back teeth. The Plan also says that the x-rays your dentist sent show that you are missing other teeth.
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 retainer crowns and pontic when the services are medically necessary and reasonable. 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 retainer crowns and pontic. Our reviewer says that you need these services. Our physician reviewer found replacing the missing maxillary posterior teeth (#'s 3 and 15) is not reasonable since there would be no change in your masticatory function due to the drifting of tooth #2 into #3's space and the partial occlusal contact of a replaced tooth #15. Our reviewer also found that the criteria for coverage for a fixed bridge replacing tooth #9 is met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the retainer crowns and pontic have been met. Therefore, we decided that the Plan has to pre-approve porcelain retainer crowns for tooth #'s 8 and 10 and a pontic for tooth #9.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.
You asked the Plan to pre-approve a Group 3 power wheelchair and accessories. You say that you need a new power wheelchair that reclines. The Plan denied your request. The Plan says there is no documentation of your inability to shift weight, that you have pressure issues, you utilize catheterization, or that you need to manage spasticity.
The Plan follows Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file does show that your current power wheelchair does not meet your needs. Criteria for a power seating system have not been met. This means that Medicare rules for coverage of a replacement PMD have not been met. The Plan has approved repairs to your current power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray provided to the enrollee on August 28, 2019.You asked the Plan to pay forthe x-ray. The Plan denied your request. The Plan says there is no diagnosis indicating this test.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 x-ray, 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 forthe x-ray provided to the enrollee on August 28, 2019
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional home health aide (HHA) visits.
You asked the Plan to pre-approve the additional HHA visits. You say that the enrollee needs to continue to receive these services. The Plan denied your request. The Plan says continued skilled nursing visits have been approved but ongoing HHA care is not needed.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 additional HHA visits. Our reviewer says that the requested HHA visits are not medically necessary. Our physician reviewer found the patient is a 70 year old male diagnosed with diabetes, kidney disease, high blood pressure, Parkinson's disease, heart disease, and a history of a stroke. He lives with his spouse who is the caregiver. The caregiver(s) helps with daily living activities, which include bathing, dressing, toileting, grooming, cleaning, and meal preparation. Since there is a willing caregiver to provide personal care, there is no need for HHA visits. 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 additional HHA visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional home health aide (HHA) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient ophthalmology office visit (99203) provided October 14, 2019.
You asked the Plan to waive the copayment for the outpatient ophthalmology office visit. You say that you thought that you get one eye exam a year and you went for your eye exam and received a bill and is being told because the provider is a specialist. The Plan denied your request. The Plan says the correct cost share has been 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 $40 copay for each specialist visit for Medicare covered benefits. You have been asked to pay $40 copay for each specialist visit for Medicare covered benefits. The outpatient ophthalmology 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 outpatient ophthalmology office visit (99203) provided October 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided tothe enrollee on December 27, 2018.You asked the Plan to pay forthe services. You say that this was medically necessary testing.The Plan denied your request. The Plan says a site investigation was completed and it was found that the address listed on these claims does not house a laboratory owned by the billing company, nor has there ever been a laboratory there. As such, this claim is not payable due to the fraudulent address reported.The Plan must follow Medicare rules. Medicare rules say that all information must corroborate the documentation in the record and support that coverage criteria are met.In this case, the Plan attests that the address listed on this claim is not valid as there is no laboratory operating at that address. As such, we find that this claim does not corroborate other information in the record and is correctly denied.Therefore, we decided that the Plan does not have to pay forthe services provided to the enrollee on December 27, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services (1123F, G8427, 99356, 99309) provided on August 8, 2019.You asked the Plan to pay for the physician services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were provided out-of-network and were not preauthorized or emergent. There were in-network providers that could provide the services at issue.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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the physician services (1123F, G8427, 99356, 99309) provided on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the shoulder and wrist orthoses or waive the copayment for the x-rays provided from July 31, 2019 to August 28, 2019.
You asked the Plan to waive the coinsurance for the shoulder and wrist orthoses and waive the copayment for the x-rays. You say that you should not have to pay because the physician did not treat you correctly. The Plan denied your request. The Plan says that the claims processed 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 20% coinsurance for Durable medical equipment (DME) and related supplies and pay a $15 copayment for Basic Radiological Services in a specialist's office. You have been asked to pay a 20% coinsurance for the shoulder and wrist orthoses and a $15 copayment for the x-rays. The shoulder and wrist orthoses fall within the Durable medical equipment (DME) and related supplies benefit category. The x-rays fall within the Basic Radiological Services in a specialist's office 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 shoulder and wrist orthoses and waive the copayment for the x-rays provided from July 31, 2019 to August 28, 2019.