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

We decided that the Plan does not have to pre-approve Xalkori.
You asked the Plan to pre-approve Xalkori. The Plan denied your request. The Plan says that they do not cover outpatient prescription drugs.
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 Xalkori.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care supplies provided on May 28, 2019.
You asked the Plan to pay for the wound care supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation did not include the wound care supplies and the physician order is signed after the delivery/service date.
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 billed items cannot be verified. There is significant variation in the dates. Therefore, we decided that the Plan does not have to pay for the wound care supplies provided on May 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on October 1, 2019.
You asked the Plan to waive the copayment for the eye exam. The Plan denied your request. The Plan says you are liable for a $50 copayment for the medical eye exam provided on October 1, 2019.
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 $50 copayment for vision care, medical eye exam. You have been asked to pay $50 copayment for the eye exam. The eye exam falls within the Vision Care, Medical Eye Exam 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 an eye exam provided on October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forstandard wheelchair (CPT Code K0001) provided to the enrollee on April 27, 2019.You asked the Plan to pay forthe standardwheelchair. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the durable medical equipment is not medically necessary.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the standard wheelchair. Our physician reviewer found the provided medical records do not document that the patient meets the requirements listed inthe Local Coverage Determination for Medicare coverage for a manual wheelchair.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 standard wheelchair have notbeen met.Therefore, we decided that the Plan does not have to pay forstandard wheelchair (CPT Code K0001) provided to the enrollee on April 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Belatacept injections provided from June 28, 2019 to July 26, 2019.
You asked the Plan to waive the coinsurance for the injections. You say that you cannot afford these infusions. The Plan denied your request. The Plan says you were charged 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% coinsurance for Medicare Part B prescription drugs. You have been asked to pay 20% coinsurance for the injections. The injections fall within the Medicare Part B prescription drugs 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 coinsurance for the Belatacept injections provided from June 28, 2019 to July 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided June 15, 2019 to June 18, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the admitting physician determined that the safest, most appropriate and medically necessary course of treatment was to admit this enrollee to the hospital as an inpatient. The Plan denied your request. The Plan says inpatient admission was 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 the medical records provided indicate that the admitting physician expected the enrollee's admission to span two midnights. Care provided to the enrollee was observation level. The enrollee remained with stable vital sounds and no recurrent bleeding. There were no advance interventions or complex medical conditions. She had stable vital signs and no complaints at the time of admission.
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 June 15, 2019 to June 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forlimited oral evaluation, problem focused (D0140) provided on October 10, 2019.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you exhausted your benefit frequency limit.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.You exhausted your benefit frequency limit, because you already had this service on November 20, 2018. Your EOC clearly states, limited oral evaluation, problem focused (D0140) limited to once per patient per provider.Therefore, we decided that the Plan does not have to pay forlimited oral evaluation, problem focused (D0140) provided on October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Prodigy Autocode monitor system.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that you are
physically able to use the preferred meters and there is no medical reason for you to have this particular meter.
The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers.
The item at issue is a Prodigy Autocode monitor system. Prodigy is not a preferred provider with the Plan for
diabetic supplies. Accu-Chek and Trividia are the preferred providers. Therefore, we decided that the Plan does
not have to pre-approve a Prodigy Autocode monitor system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveViberzi for the enrollee.You asked the Plan to pre-approveViberzi. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that this is not covered under Part B.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-approveViberzi for the enrollee.Benefits for Viberzimay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit services provided on June 25, 2019.
You asked the Plan to pay for the home visit services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 home visit services provided on June 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment/no transport (A0998) provided on July 16, 2019.
You asked the Plan to pay for ambulance response and treatment/no transport. You say that the records should support the necessity of the services. The Plan denied your request. The Plan says this service is 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 16, 2019. 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 ambulance response and treatment/no transport (A0998) provided on July 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a contact lens fitting and a refraction provided on May 29, 2019.You asked the Plan to pay for the contact lens fitting and the refraction.The Plan denied your request. The Plan says contact lens fitting and refractions are excluded from coverage.Medicare generally does not cover routine vision services. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.The Plan contract does not provide coverage for contact lens fitting.We looked at the file, Medicare's rulesand the Plan's rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. The Plan does not provide coverage for contact lens fitting.Therefore, we decided that the Plan does not have to pay fora contact lens fitting and a refraction provided on May 29, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from June 11, 2019 through August 21, 2019.You asked the Plan to pay forinpatient mental health 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 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 pay for inpatient mental health care. Our physician reviewer found based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of August 3, 2019 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors being cooperative and compliant.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from June 11, 2019 through August 21, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to D. Hogle by Ascension Living on May 1, 2019 to May 24, 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 the claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that home health claims must be billed with a functional G code. We looked at the file and Medicare rules. The file shows that the claims were not billed with the required functional G codes. 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 home health services rendered to D. Hogle by Ascension Living on May 1, 2019 to May 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on March 8, 2019.
You asked the Plan to pay for non-emergent ambulance services. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. The member was not in critical condition. She had stable vital signs. There was no evidence of the need for ambulance transportation. Other means of transportation could be used without endangering the individual's health. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on March 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood pressure monitor given to enrollee on August 8, 2019.
You asked the Plan to pay for the blood pressure monitor. You say that the Plan should pay this claim. The Plan denied your request. The Plan says ambulatory blood pressure monitoring is only covered for white coat syndrome and performed for 24 hours.
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 A4670 is automatic bp monitor, dial. We find that CPT code A4670 is not separately payable. Specifically, an automatic bp monitor A4670 is durable medical equipment not a service code. Also items and services during ambulance services are not paid separately. Based on this information, we decided that Medicare rules for coverage of the blood pressure monitor have not been met. Therefore, we decided that the Plan does not have to pay for the blood pressure monitor given to enrollee on August 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for a radiologic examination provided on July 23, 2019.
You asked the Plan to pay for the physician's services for a radiologic 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 physician's services for a radiologic examination provided on July 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on May 1, 2019.
You asked the Plan to pay for drug test. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab test billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on May 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe comprehensive hearing test provided on August 15, 2019.You asked thePlan to waive the copayment forthe comprehensive hearing test. You say that you requested a free yearly routine hearing exam. You say you should not have a 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 $50 copayment for each in-network Medicare-covered visit. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $50 copayment for the comprehensive hearing test.You have been asked to pay a $39.37 copayment for the comprehensive hearing test. The comprehensive hearing test falls within the "Hearing services" benefit category. The medical record shows a diagnosis of sensorineural hearing loss of both ears. Therefore, the comprehensive hearing test is diagnostic in nature.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 comprehensive hearing test provided on August 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on July 17, 2019 by out of network provider, "the provider". You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-network 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 referring provider 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 laboratory services provided on July 17, 2019 by out of network provider, "the provider".
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray services provided on July 11, 2019.
You asked the Plan to pay for the x-ray services. 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
x-ray services. 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 x-ray services provided on July 11, 2019.