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

We decided that the Plan does not have to pay for the vitamin D testing you received on February 19, 2020.You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare rules say that vitamin D testing is not covered for any diagnosis code not listed in the applicable LCA. We looked at the file and Medicare rules. The testing in question was billed with diagnosis code R53.83. This diagnosis code is not listed as a covered code according to A57736. This means that the requested vitamin D testing is not covered medically necessary for the billed diagnosis code. 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 vitamin D testing you received on February 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of a skilled nursing facility admission. The Plan says that SNF care is not medically necessary.
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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require SNF level nursing or SNF level therapy to improve his current condition, to maintain his current condition, or to prevent or slow further deterioration of his condition. There are no complex skilled nursing needs such as new enteral feedings, IV antibiotics, complex wound care. The enrollee did not require the skills of a professional therapist at a SNF level to improve his current condition, to maintain his current condition, or to prevent or slow further deterioration of his condition. He was approved for outpatient level therapy on May 6, 2020. He does not require daily skilled therapy or daily skilled nursing. 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 pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for glucose monitor supplies (K0553) provided on October 27, 2019.You asked the Plan to pay for glucose monitor supplies. You say that this was medically necessary and the required documentation has been submitted.The Plan denied your request. The Plan says the supporting documentation does not match the information sent on the claim.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 physician order and 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 supplies at issue were billed for October 27, 2019. This is neither the shipping date nor the delivery date shown on the proof of delivery submitted in the file as required by Medicare rules.Therefore, we decided that the Plan does not have to pay for glucose monitor supplies (K0553) provided on October 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from December 18, 2019 to December 27, 2019.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the out-of-network charges because the service was necessary.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 $395 copayment each day for days 1-4 for inpatient hospital care. You had an inpatient hospital stay from December 18, 2019 to December 27, 2019. Therefore, you are responsible to pay a $395 copayment for days 1-4 (December 18, 2019 to December 21, 2019). $395 (copayment) x 4 (inpatient days) = $1,580.You have been asked to pay the total copayment amount of $1,580 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 waive the copayment for an inpatient hospital stay provided from December 18, 2019 to December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 20, 2020.
You asked the Plan to waive the copayment for the office visit. You say that this was a follow up for a sleep study. You say that the charge should be removed. The Plan denied your request. The Plan says the copayment 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 a $50 copayment for specialist visits. You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was to assess your sleep apnea. 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 office visit provided on January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.
You asked the Plan to pre-approve hearing aids. The Plan denied your request. The Plan says the coverage
criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related
services.
Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these
types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aids.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided from December 30, 2019 through December 31, 2019. You asked the Plan to waive the copayment for the ER visit. You say that there was something wrong and you should have been admitted. You say that you shouldn't have to pay. The Plan denied your request. The Plan says the copayment 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 a $90 copayment for emergency services in an emergency room. You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the ER. 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 ER visit provided from December 30, 2019 through December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833 and L2937) provided on January 14, 2020.
You asked the Plan to pay for the knee brace. You say that you would like reconsideration because these supplies are medically necessary. The Plan denied your request. The Plan says the documentation submitted does not indicate that the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee brace have not been met. Specifically, the record indicates that the Plan requested documentation showing that the provider discussed the need for these supplies with the member. There is insufficient information to verify the billed supply codes. Therefore, we decided that the Plan does not have to pay for a knee brace (L1833 and L2937) provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases
and/or electricity, water and/or phone bill payments.
You asked the Plan to pre-approve a debit card for an allowance for healthy food purchases and/or electricity,
water and/or phone bill payments. The Plan denied your request. The Plan says the certification provided from
your physician documented that the enrollee has only one of the qualifying diagnoses (peripheral vascular
disease). The enrollee does not require intense care coordination, has no high risk for hospitalizations or high
risk for adverse health outcomes and for these reasons the enrollee does not meet the criteria
The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and
medically complex chronic conditions that are life-threatening or significantly limit your health or general
functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and
must require intensive care coordination.
We looked at the file and the Plan's rules. The file shows that although you have one of the qualifying
diagnoses, you do not have a high risk for hospitalizations or a high risk for adverse health outcomes and for
these reasons you do not meet the criteria. Based on this information, we decided that the Plan's rules for
coverage of a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill
payments have not been met. Therefore, we decided that the Plan does not have to pre-approve a debit card for
an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided from September 9, 2019 to September 10, 2019.
You asked the Plan to pay for the laboratory services. You say that the claim has not been paid in full or under the terms of the contract for the services provided to the enrollee. 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 enrollee 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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services provided from September 9, 2019 to September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exercise bike.
You asked the Plan to pre-approve the bike. You say that your leg is getting stiff due to a lack of movement.
The Plan denied your request. The Plan says physical fitness equipment, such as exercise bikes, are considered
non-medical.
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-approve an exercise bike.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic shoes provided on November 26, 2019 by an out of network (OON) provider.You asked the Plan to pay for the OON services. You say that you received the shoes but you do not use them.The Plan denied your request. The Plan says 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 has network providers available who can provide the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items.Therefore, we decided that the Plan does not have to pay for the diabetic shoes provided on November 26, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe ambulance transport and the inpatient hospital stay provided from January 5, 2020 to January 9, 2020.You asked the Plan to waive the copayments forthe ambulance transport and the inpatient hospital stay. You say that you say the charges are excessive.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 $250 copayment for each one-way Medicare-covered ambulance transport and a $325 copayment per day, days 1-5 for each in-network Medicare-covered hospital admission/stay. You have been asked to pay a $250 copayment for the ambulance transport. You have also been asked to pay a $325 copayment per day, for 3 days of the inpatient hospital stay. ($325 x 3= $975). The ambulance transport falls within the "Ambulance services" benefit category. The inpatient hospital stay falls within the "Inpatient hospital care"benefit category. This means that you have been asked to pay the correct amount based on yourcontract 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 copayments forthe ambulance transport and theinpatient hospital stay provided from January 5, 2020 to January 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) and discharge day management (99239) provided from September 24, 2019 to September 26, 2019.
You asked the Plan to pay for critical care and discharge day management. You say that these services should be covered. The Plan denied your request. The Plan says these codes are not supported in the records.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99291 and 99239 is not supported in the medical record. Both of these codes are specifically for more than 30 minutes of service. The submitted medical records do not document the time spent on these services, therefore, these codes cannot be verified. Based on this information, we decided that Medicare rules for coverage of critical care and discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) and discharge day management (99239) provided from September 24, 2019 to September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality test (D0460) provided on January 21, 2020.You asked the Plan to pay for the dental service. You say that this consultation was a result of an abscess of the gum that had been treated with 10 days of antibiotics. You say that it was crucial to investigate what caused the infection so that it could be treated properly. You also say that this was an urgent medical condition and should be covered as such.The Plan denied your request. The Plan says the pulp vitality test is not listed as a covered service.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 pulp vitality test is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the pulp vitality test (D0460) provided on January 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.
You asked the Plan to pre-approve Procrit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Procrit. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of Anemia in chronic kidney disease. The documentation does not support that the enrollee has tried and failed Retacrit. The documentation does not support that Retacrit (Epoetin alfa-epbx) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services received on February 26, 2020.
You asked the Plan to pay for the serivces. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered Medicare benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services received on February 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization.
You asked the Plan to pre-approve inpatient psychiatric hospitalization. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that inpatient admission is covered when certain criteria is met. 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 inpatient psychiatric hospitalization. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided for the admission of this enrollee, criteria for acute inpatient mental health treatment has not been met as she was not shown to be a danger to herself or others and was not experiencing auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors.
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 psychiatric hospitalization have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.You asked the Plan to pre-approve the compression stockings. You say that you have a condition and it is the plan's job to assist and provide these stockings and that is the reason you pay for a plan. You have clots in both legs and the stockings are needed.The Plan denied your request. The Plan says this service is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.