Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthephysical therapy provided from May 2, 2019 to May 30, 2019.You asked the Plan to pay forthe physical therapy. You say that the medical records show the services were not related to the member's hospice diagnosis.The Plan denied your request. The Plan says Original Medicare is responsible for payment of all Medicare-covered services related or unrelated to the member's terminal illness.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.The record shows proof of hospice election from February 5, 2019 to October 2, 2019. Therefore, we decided that the Plan doesnot have to pay forthe physical therapy provided from May 2, 2019 to May 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the
device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using
the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device
(E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided by HNC Medical Supplies from August 1, 2019 to October 20, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided by HNC Medical Supplies from August 1, 2019 to October 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the general anesthesia (D9223), drugs or medicaments (D9630), implants (D6010) for teeth # 4, 7, 10, and 12, osseous surgery (D7950) for teeth # 8 and 9, sinus augmentation (D7951) for the upper left and upper right quadrants, dental case management (D9997), and a post-op office visit.
You asked the Plan to pre-approve the dental services. You say that the Plan will not grand you an extension on an appeal. You say that you were on the phone with the Plan for almost 3 hours and everyone gave you a different answer. The Plan denied your request. The Plan says the requested dental services are not listed as covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the general anesthesia (D9223), drugs or medicaments (D9630), implants (D6010) for teeth # 4, 7, 10, and 12, osseous surgery (D7950) for teeth # 8 and 9, sinus augmentation (D7951) for the upper left and upper right quadrants, dental case management (D9997), and a post-op office visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (code D4381 x4) provided on August 20, 2019.
You asked the Plan to pay for the localized delivery of antimicrobial agents. You say that you had the deep cleaning done because you were informed that the plan would pay for the service and you would only be responsible for paying the copay. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (code D4381 x4) provided on August 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's appropriate therapy needs are not precluded in an alternate level of care.
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 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 documentation does not reveal that the enrollee required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive rehabilitation facility therapy program 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 physician services provided to the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided from April 27, 2019 through May 24, 2019.
You asked the Plan to waive the copayment for SNF 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 claims were processed accordingly with your 2018 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). There is a $0 copayment per day for days 1-20 and a $160 copayment per day, for days 21-42 at a SNF. You were admitted to the SNF on April 27, 2019 through discharge on May 24, 2019, which is a total of 27 days for this SNF admission. Therefore, application of the $160 copayment for 7 of the SNF days was appropriately applied and the request for a waiver in the amount of $1,120 for SNF copayments incurred for services you received at the facility is denied. 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 SNF care provided from April 27, 2019 through May 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on January 19, 2019.
You asked the Plan to pay for acute inpatient hospital 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the records provided at the time of inpatient admission care at the observation level appeared to be appropriate with the option to move the patient to inpatient status when and if it became clear that the patient's hospital stay would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on January 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe x-ray provided on October 23, 2019.You asked the Plan to waive the copayment forthe x-ray. You say that the doctor did not use x-ray you brought, instead, she took her own x-ray for your diagnosis. You say you do not feel you should be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $10 copayment for x-rays, laboratory and other diagnostic tests for each category per service date (this copayment does not apply to interpretation costs). You have been asked to pay a $10 copayment for the x-ray. The x-ray falls 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 copayment forthe x-ray provided on October 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.
You asked the Plan to pay for the paramedic intercept services. You say that you were told that you would only have to pay for the ambulance copay. An ambulance was called after you were found on the side of the road with head injuries. You say that you believe the paramedic intercept services should be covered. The Plan denied your request. The Plan says this item is not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an Automated External Defibrillator (AED) provided from April 16, 2019 to May 16, 2019.
You asked the Plan to waive the coinsurance for the AED. You say that the equipment didn't function correctly and the coinsurance should be waived. The Plan denied your request. The Plan says the correct coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 15% coinsurance for Durable Medical Equipment. The enrollee has been asked to pay a 15% coinsurance for the AED. The AED falls within the Durable Medical Equipment benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an Automated External Defibrillator (AED) provided from April 16, 2019 to May 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee has been admitted to the hospital many times and cannot be managed by any SNF. Care in a long term acute facility will allow him to receive the care he needs to reduce readmission.The Plan denied your request. The Plan says there are no services that an LTACH can provide that cannot be provided equally at the current facility for as long as is necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is currently undergoing treatment at an ACH for chronic shortness of breath in the setting of CHF and pleural effusions. The enrollee is receiving supplemental oxygen and BiPAP. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.We looked at thisphysician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (CPT Code E0466) provided on August 20, 2019.
You asked the Plan to waive the coinsurance for the 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 DME provided on August 20, 2019. You are asked to pay 20% coinsurance for DME. 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 home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (CPT Code E0466) provided on August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ophthalmological medical examination and evaluation
provided on August 6, 2019.
You asked the Plan to pay for the ophthalmological medical examination. The Plan denied your request. The
Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of
network providers when possible and 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 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 an ophthalmological medical examination and evaluation
provided on August 6, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. You say that the requested Synvisc-One is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail the preferred drugs, Orthovisc and Monovisc first.
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 Synvisc-One. Our reviewer says that the plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with bilateral knee pain and a diagnosis of bilateral knee osteoarthritis. The enrollee failed conservative treatment. Synvisc-One injection is being requested. The provided medical records do not indicate that the enrollee has tried and failed the required drugs. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on August 14, 2019, by an out-of-network provider.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says they will not cover services from a non-participating provider during an unapproved stay at the skilled nursing facility.
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. Previous claims have been paid for services rendered for this member during his approved stay at the skilled nursing facility. However, these services occurred after the approval for the members stay had expired. The member was issues a notice of Medicare non coverage on August 8, 2019. The member then transitioned to private pay. The Plan will not cover services from a non-participating provider during an unapproved stay at the skilled nursing facility. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on August 14, 2019, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the
device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using
the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device
(E0652).