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

We decided that the Plan does not have to pay for IV tubing extension set described by code S1015 and infection control supplies described by code S8301 provided on December 17, 2020.You asked the Plan to pay for codes S1015 and S8301. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. In this case, CPT codes S1015 and S8301 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. 
Medicare uses other codes for reporting of, and payment for, these services.Therefore, we decided that the Plan does not have to pay for IV tubing extension set described by code S1015 and infection control supplies described by code S8301 provided on December 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services for 14 hours a week for dates of service April 8, 2021, through June 6, 2021.You asked the Plan to pre-approve the home health aide services for 14 hours a week for dates of service April 8, 2021, through June 6, 2021.The Plan denied your request. The Plan says there is no documentation to show that the enrollee has a skilled need other than medication administration already provided by a visiting nurse. There is no documented need for a home health aide to do hands on personal care or services needed to maintain the enrollee's health or facilitate treatment of the enrollee's illness or injury.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 home health aide services for 14 hours a week for dates of service April 8, 2021, through June 6, 2021. Our reviewer says that home health aide services are not reasonable and necessary.Our physician reviewer found based on the medical records provided there is no documentation that the services meet the definition of home health aide services. Based on the medical records provided there is no documentation that the home health aide services are reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. The records do not document a need for home health aide services.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 home health aide 14 hours a week for dates of service April 8, 2021, through June 6, 2021. have not been met.Therefore, we decided that the Plan does not have to pre-approve home health aide services for 14 hours a week for dates of service April 8, 2021, through June 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on November 30, 2020 by a
non-participating provider.

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 the services were rendered by a non-participating provider without 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the podiatry services provided on November 30, 2020 by a non-participating provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on October 14, 2020 to October 20, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 

We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on October 14, 2020 to October 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provide on July 15, 2020.

You asked the Plan to pay for the ambulance services. 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 does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on July 15, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services provide on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fillings (D2335 x4, D2394) provided from June 10, 2020, through December 21, 2020.

You asked the Plan to pay for fillings. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says the services at issue are not covered 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. 

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 fillings (D2335 x4, D2394) provided from June 10, 2020, through December 21, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) provided on October 21, 2020.

You asked the Plan to pay for the transportation service. You say that this claim was underpaid in error. You say that You also say that the service was medically necessary.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) provided on October 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on January 21, 2021, and January 22, 2021.You asked the Plan to pay for the self-administered drugs. You say that you did not self-administer any drugs.The Plan denied your request. The Plan says self-administered drugs are not covered under Part B of Original Medicare.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 pay for the self-administered drugs provided on January 21, 2021, and January 22, 2021.
Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on February 15, 2021.You asked the Plan to pay for the bone replacement graft. You say that you would like this service to be covered.The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on February 1, 2021.You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.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 does not contain a valid proof of delivery or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the eye exam provided on January 19, 2021.
You asked the Plan to reduce the copayment for Ophthalmological services: medical examination and evaluation (92012). You say that your copayment should only be $25. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for Vision Care. You have been asked to pay a $40 copayment for Ophthalmological services: medical examination and evaluation (92012). Ophthalmological services: medical examination and evaluation (92012) falls within the
Vision Care 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 copayment for the eye exam provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64491, 64490).You asked the Plan to pre-approve the facet joint injections. You say that the injections are medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that for injections to be covered, there must be no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain.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 facet joint injections. Our reviewer says that the injections are not medically necessary. Our physician reviewer found there are other possible pain generators, specifically spinal stenosis.Additionally, a current Physical exam needs to be documented before any intervention is performed.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 facet joint injections have not been met.Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64491, 64490).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on March 1, 2021.You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this service should be covered.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. The only exams included under your dental benefit are routine oral exams and comprehensive oral exams.Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on March 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on February 18, 2020.

You asked the Plan to pay for the physical therapy. The Plan denied your request. The Plan says the
documentation submitted on appeal consists of duplicates of medical documents previously reviewed.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to
justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the
physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy provided on February 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0425, A0427) received October 12, 2020.

You asked the Plan to waive the copayment for the ambulance transportation services. You say that you cannot afford the copayment.The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 one-way trip on Medicare-covered emergency and non-emergency ambulance transportation. 

You have been asked to pay a $200 copayment for the ambulance transportation services. The services received are considered a one-way trip on Medicare-covered emergency ambulance transportation. 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 ambulance transportation services (A0425, A0427) received October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 9 extractions (D7140) provided on March 2, 2021.

You asked the Plan to pay for the dental services. You say that you feel you were not given the correct information when you signed up for this plan. You say that now you are stuck with a bill for $900. You say that you would not have chosen this plan if you had known these services would not be covered. You also say that you are on a limited income and cannot pay this bill. The Plan denied your request. The Plan says 1 extraction is covered per calendar year. The Plan also says that the frequency limit has been exceeded.

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 and extraction is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the extraction of tooth # 2. Therefore, we decided that the Plan does not have to pay for the 9 extractions (D7140) provided on March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmic testing services (92004, 92020, 92083, 92133) provided on August 25, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the ophthalmic exams. You say that these services should be covered as the enrollee had a referral for out-of-area care on the date of service because they were out of state for a few months. The Plan denied your request. The Plan says out-of-network care is only covered in limited circumstances. The care provided was not urgent, unforeseen or pre-approved by the Plan.

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. A blanket referral for, "other clinicians and/or diabetic educators outside of the provider network," was provided with the appeal request, but the network and contract status of the provider who issued this note is unclear. The note also does not specify any providers by name. The Plan had network providers available who could have provided the items/services at issue in this appeal and also offers a supplemental traveler/visitor benefit which can permit an enrollee to receive out-of-area services from specific pre-approved providers. There is no evidence that the enrollee participated in this benefit, this provider was pre-approved to be seen under this benefit, or that the care provided was urgent or unforeseen. 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 ophthalmic testing services (92004, 92020, 92083, 92133) provided on August 25, 2020 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 January 16, 2021, to January 24, 2021.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 SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. 
A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from August 19, 2020, to January 15, 2021. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 16, 2021, to January 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 18, 2020 by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the visit was not prescheduled which is why an authorization was not obtained prior to the services being rendered.The Plan denied your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that prior authorization was not 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 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 subsequent nursing facility care provided on November 18, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3-surface filling (D2332) provided on November 19, 2020.

You asked the Plan to pay for the dental service. You say that you never received notice that you were disenrolled from your dental coverage. You say that you have not been reimbursed for any of your recent dental services. You say that you called that plan and were advised that you have not had dental coverage since October 1, 2020. You also say that you had no idea that you did not have dental coverage. The Plan denied your request. The Plan says the 3-surface filling is not listed as a covered service. The Plan also says that the provider in this case does not participate with 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 3-surface filling (D2332) provided on November 19, 2020.

Your complaint about being disenrolled from your dental coverage 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.