Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 25, 2019 to March 1, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider did not bill with an appropriate Q code on the claim.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim submitted does not include the required Q code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 25, 2019 to March 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 15, 2020.You asked the Plan to pay for the ambulance services to a doctor's office. You say that the Plan should pay this claim.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 pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to pay for the ambulance services provided on January 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ure-Na over the counter medication for the enrollee.
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your request. The Plan says over the counter medications are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve ure-Na over the counter medication for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Promethazine HCL for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy with the 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 pre-approve Promethazine HCL for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional days of an inpatient psychiatric admission for the enrollee.You asked the Planto pre-approvethe additional days. You say that this is medically necessary, as this would be an unsafe discharge.The Plandenied your request. The Plansayscare can be received at a lower level of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 days. Our reviewer says that the requested additional days are not medically reasonable or necessary. Our physician reviewer found the enrollee does not meet the criteria for continued acute inpatient mental health treatments, as the enrollee was notshown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety.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 days have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional days of an inpatient psychiatric admission for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram and an ultrasound provided on January 3, 2020 to January 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for a mammogram and an ultrasound. You say that you feel like it is the doctor's office should verify if the facilities they are sending you to. 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 a mammogram and an ultrasound provided on January 3, 2020 to January 14, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the oxygen equipment provided on January 24, 2020.
You asked the Plan to reduce the coinsurance for the oxygen equipment. You say that you were charged too much for the oxygen equipment. 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 20% of the total cost for Medicare-covered durable medical equipment and related supplies. You have been asked to pay a total of $63.00 which is 20% of the total allowed amounts for the oxygen equipment. The total allowed amounts is $315.00. ($31500 x 20% = $63.00). The oxygen equipment falls within the "Durable medical equipment (DME) and related 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 reduce the coinsurance for the oxygen equipment provided on January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 6, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on January 16, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these services is included in the Part A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers.Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on January 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar/sacral facet injection for the enrollee. You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is not supported if there is a problem with the nerve, spinal cord, or brain function that has caused numbness or tingling of the skin or weakness in the muscles. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pre-approve the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the enrollee has had a history of at least 3 months of moderate to severe pain with functional impairment and pain is inadequately responsive to conservative care such as NSAIDs, acetaminophen, physical therapy. In addition, the requested procedure is supported if the pain is localized to the back and does not travel to other areas of your body. The records show that the enrollee's pain is associated with radiculopathy. Therefore, the requested lumbar/ sacral facet injection is not medically necessary. 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 Plan does not have to pre-approve a lumbar/sacral facet injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on January 18, 2020.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room during this length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on January 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear stress test provided on October 9, 2019.
You asked the Plan to waive the copayment for the nuclear stress test. You say that you should not be responsible for the additional charge. 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 $200 copayment for each type of Medicare-covered diagnostic radiology service including MRI, CT scans, nuclear scans and PET scans, per date of service. You have been asked to pay a $200 copayment for the nuclear stress test. The nuclear stress test 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 for the nuclear stress test provided on October 9, 2019.
Your complaint about the complication that the nurse could not find your vein is 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that the member presented an address. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on November 25, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is status-post fall and right trochanteric fracture. The documentation supports that the enrollee's medical conditions appear stable. There are no complex wound care needs. The documentation does not support that the enrollee required medical oversight of their condition at an acute hospital level of care. While the enrollee requires additional physical therapy and occupational therapy, the enrollee does not require an intensive therapy program provided at an IRF level of 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on September 19, 2019.
You asked the Plan to pay for this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says the enrollee was under hospice election at the time of service.
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 physician services provided to the enrollee on September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Resin-based composite, three services, posterior (tooth 32) (D2393) and topical application of fluoride, excluding varnish (D1208) provided February 1, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing the denial of the dental services as you feel that you had to have this taken care of right away. The Plan denied your request. The Plan says these services are not covered under the plan benefits.
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 health plan contract says that procedures not listed are not covered. 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 Resin-based composite, three services, posterior (tooth 32) (D2393) and topical application of fluoride, excluding varnish (D1208) provided February 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair power seat elevation feature.You asked the Plan to pre-approvea power seat elevation feature (E2300). You say that you need the seat elevation feature for activities of different heights through your house.The Plan denied your request. The Plan says seat elevation features are not primarily medical in nature therefore not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea power wheelchair power seat elevation feature.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe DME provided to the enrollee on April 18, 2019by an out-of-network provider.You asked the Plan to pay forthe DME. You say that the Plan is required to pay non-contracted providers and its suppliers based on the Medicare Managed Care Manuals.The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.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 forthe DME provided to the enrollee on April 18, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the epoetin alfa injections rendered on October 2, 2019 to October 30, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code Q4081 was not billed with the required modifier. The Plan must follow Medicare rules. The rules say that the required route of administration modifiers for dialysis services are JA, JB and JE. We looked at the file and Medicare rules. The file shows that epoetin alfa injections were provided for dialysis services. Procedure code Q4081 was not billed with one of the required administrative modifiers for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the epoetin alfa injections rendered on October 2, 2019 to Otober 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the intravitreal injection, aflibercept injection and ophthalmic imaging provided on January 3, 2020.
You asked the Plan to waive the cost share for the intravitreal injection, aflibercept injection and ophthalmic imaging. You say that you had been getting the same services and nothing changed. You say that you do not agree with 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 20% of the cost for Part-B covered chemotherapy drugs and other Part-B covered drugs and a $50 copayment for all other diagnostic procedures and tests. Your contract with the Plan clearly says that you must pay a $40 copay for each specialist in-person office visit. Covered services include medically-necessary medical care or surgery services furnished in a physician's office.
You have been asked to pay a total of $441.05 for the intravitreal injection, aflibercept injection and ophthalmic imaging.
The intravitreal injection falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The aflibercept injection falls within the "Medicare Part B prescription drugs" benefit category. The ophthalmic imaging 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 cost share for the intravitreal injection, aflibercept injection and ophthalmic imaging provided on January 3, 2020.