Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ranibizumab, eye drug injection, scanning computerized ophthalmic diagnostic imaging, and eye exam provided on November 19, 2019.You asked the Plan to pay for the Ranibizumab, eye drug injection, scanning computerized ophthalmic diagnostic imaging, and eye exam. You say that you spoke with a Plan representative and told them that even though the enrollee was in hospice, your services were not related to the hospice. You also say that previous dates of service while the enrollee was in hospice were paid for by the Plan.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 Ranibizumab, eye drug injection, scanning computerized ophthalmic diagnostic imaging, and eye exam provided on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Waterproof tape (A4452), Skin barrier, wipe or swab
(A5120), Collagen dressing, sterile, size 16 sq. in. or less, each (A6021), Gauze, non-impregnated, sterile, pad
size 16 sq. in. or less, without adhesive border, each dressing(A6402) and Tubular dressing with or without
elastic, any width, per linear yard (A6457) provided to the enrollee on July 16, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request.
The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. During the course of the original
investigation, a review was conducted of the submitted documentation for date of service July 16, 2019. This
review determined that the billed services were not supported. An appeal was submitted. The documentation
submitted during the course of the original investigation was again thoroughly reviewed.
Healthcare Common Procedure Coding System (HCPCS) codes A6021 A1 (30 Units), A6402-A1 (30 Units)
and A6457-A1 (2 Units) remains not supported. The documentation submitted did not include proof of delivery
to corroborate with the submitted Delivery Ticket. Therefore, the billed supply code cannot be verified. It is
noted that multiple attempts were made to contact the provider for additional information.
As the HCPCS codes A4452 and A5120 were not billed with the required durable medical equipment modifier;
we find that Medicare rule for payment of this claim has not been met. If the provider determines that a billing
error occurred during the initial submission of the denied claim, the plan would accept a submission of a
corrected claim to consider services for payment. You can find the above guidelines on the Medicare website at
https://www.cms.gov. Therefore, we decided that the Plan does not have to pay for Waterproof tape (A4452),
Skin barrier, wipe or swab (A5120), Collagen dressing, sterile, size 16 sq. in. or less, each (A6021), Gauze,
non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing(A6402) and
Tubular dressing with or without elastic, any width, per linear yard (A6457) provided to the enrollee on July
16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October 16, 2019 to November 7, 2019.You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services.The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October 16, 2019 to November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on August 27, 2019.
You asked the Plan to pay for the assembly and operation of a pump with oxygenator or heat exchanger. You say that this was a necessary service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on August 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Positron Emission Tomography (PET) scan (78492) provided December 9, 2019.
You asked the Plan to waive the copayment for the PET scan. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for Advanced Imaging. You have been asked to pay a $300 copayment for the PET scan. The PET scan falls within the Advanced Imaging 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 a Positron Emission Tomography (PET) scan (78492) provided December 9, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and basic life support services provided on November 4, 2019.
You asked the Plan to pay for the transportation services. You say that you billed hospice for the services. You say that it was denied for the service not being not ordered or not related to hospice. You also say that you billed the service with the correct modifier and i he claim was still denied. 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. The Plan also says that the enrollee's hospice benefit covers all hospice care from the effective date of election to the date of discharge or revocation.
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 ground mileage and basic life support services provided on November 4, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 occupational therapy visits.
You asked the Plan to pre-approve occupational therapy. The Plan denied your request. The Plan says the enrollee no longer requires the skills of a licensed therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 occupational therapy. Our physician reviewer found that the requested therapy is not generally accepted as specific and effective therapy for the patient's condition. The enrollee has had extensive prior therapy, and the documentation does not reveal significant objective functional improvement from this therapy. She has assist for activities of daily living in her long term care facility. Her records do not indicate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus shot received on January 3, 2020.
You asked the Plan to pay for the services. You say that this was necessary as a precaution. The Plan denied your request. The Plan says this is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for a tetanus shot received on January 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora lab test provided on December 16, 2019 by an out of network (OON) provider.You asked the Plan to pay fora lab test. You say that this service does not require prior authorization. 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.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 fora lab test provided on December 16, 2019 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 24, 2019 to November 28, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says while on Hospice, skilled nursing facility level services are not a covered benefit.
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 skilled nursing services provided from November 24, 2019 to November 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits provided on January 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON 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 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 the office visits provided on January 23, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for antireflective coating, per lens (V2750) purchased October 25, 2019.
You asked the Plan to pay for the vision services. You say that you needed to replace your broken glasses promptly. You should not be penalized because of ambiguous language and respectfully ask that your claim for eye glass frame be reimbursed. The Plan denied your request. The Plan says vision services must be provided by an in-network provider. The plan allowed a one-time exception and approved reimbursement of $260. Upgrades are not covered under the plan benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract specifically says additional options including but not limited to tinting, transitions, anti-reflective coating are not covered.
We looked at the file and the Plan's rules. Additional options or upgrades are not covered by the plan. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for antireflective coating, per lens (V2750) purchased October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on September 6, 2019.
You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 anesthesia services provided on September 6, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services, chest x-ray, ECG tracing, and ED visit provided on September 17, 2019.You asked the Plan to pay forthe laboratory services, chest x-ray, ECG tracing, and ED visit. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee.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 forthe laboratory services, chest x-ray, ECG tracing, and ED visit provided on September 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Inderal LA 120mg capsule.
You asked the Plan to pre-approve Inderal LA 120mg capsule. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Inderal LA 120mg capsule.
Benefits for Inderal LA 120mg capsule may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Prometheus IBD sgi diagnostic test provided to the
enrollee on July 22, 2019.
You asked the Plan to pay for the testing. You say that these tests were needed to verify a lack of medication
prior to starting a medication. The Plan denied your request. The Plan says this test is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that the rometheus IBD sgi diagnostic test is not a
covered benefit.
There is a lack of evidence to support the use of this test. Based on this information, we decided that Medicare
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay
for the Prometheus IBD sgi diagnostic test provided to the enrollee on July 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
You asked the Plan to pre-approve a Freestyle Libre 14 day sensor. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 Freestyle Libre 14 day sensor. Our reviewer says that the item is not medically necessary. Our physician reviewer found you do not take insulin and we are not told what the blood glucose data from the libre will be used for. Namely, if it would be used to adjust your medication dose or your diet. Also, we are not told why frequent blood glucose checks, which the libre can assist with, is medically needed rather than using a glucometer; hence the provided criteria are not 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 a Freestyle Libre 14 day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bupivicaine hydrochloride injection services coded S0020 provided on November 8, 2019.You asked the Plan to pay for the bupivicaine hydrochloride injection services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.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 S0020 is injection, bupivicaine hydrochloride, 30 ml.We find that CPT code S0020 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the bupivicaine hydrochloride injection services have not been met.Therefore, we decided that the Plan does not have to pay for the bupivicaine hydrochloride injection services coded S0020 provided on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 1, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with 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 $35 copayment for each specialist visit. You have been asked to pay a $35 copayment for a specialist visit. A specialist 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 a specialist visit provided on November 1, 2019.