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

We decided that the Plan does not have to pay for the ground mileage (A0425), and the non-emergency transport (A0428) provided on April 30, 2020.

You asked the Plan to pay for the transportation services. You say that the denial states that the enrollee was enrolled in hospice. You also say that the enrollee was disenrolled from hospice prior to the date of service. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on April 3, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425), and the non-emergency transport (A0428) provided on April 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.You asked the Plan to pre-approve a portable oxygen concentrator (E1392). You say that you need a portable oxygen concentrator so you can work as driver.The Plan denied your request. The Plan says the documentation received does not indicate that lighter portable oxygen tanks would not satisfy your portable oxygen needs within the home.The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. We looked at the file and Medicare rules. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator (E1392) have not been met.Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic parenteral drugs, two or more administrations, different medications (D9612).
You asked the Plan to pre-approve the therapeutic parenteral drugs, two or more administrations, different medications (D9612). You say that the requested service is necessary. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.
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 pre-approve the therapeutic parenteral drugs, two or more administrations, different medications (D9612).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network provider.
You asked the Plan to pre-approve out-of-network physical therapy. You say that you had previous success with this provider and the orthopedic surgeon recommends them. The Plan denied your request. The Plan says in-network providers are 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on October 28, 2020 to November 11, 2020 by an out of network (OON) provider.You asked the Plan to pay for the outpatient hospital services provided by an OON provider. 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 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 outpatient hospital services provided on October 28, 2020 to November 11, 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 the determination of refractive state (92015) received December 28, 2020.
You asked the Plan to pay for the eye refraction. You say that the refraction was required in order to determine the necessary corrective lenses following the insertion of intraocular lenses. The Plan denied your request. The Plan says this claim is for post-cataract care; therefore, it cannot be covered under your routine benefit.
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 Plan covers these services when [Insert why/when the plan covers routine vision]. We looked at the file and the Plan's rules. Original Medicare does not cover routine eye exams (eye refractions) for eyeglasses or contacts. Refractive procedures are not covered even when performed in connection with otherwise covered diagnosis or treatment of illness or injury. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) received December 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two-way silver alloy coated indwelling catheters (A4338) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the indwelling catheters. You say that you have been paying out of pocket for the past 3 years because this is the only provider that has them. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve two-way silver alloy coated indwelling catheters (A4338() to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Neurology and Neuromuscular services represented by codes 95886 and 95910 provided on November 19, 2020.
You asked the Plan to pay for codes 95886 and 95910. You say that the medical records support the billing of CPT codes 95886 and 95910 provided on 11/19/20. The Plan denied your request. The Plan says the medical records do not support the billing of CPT codes 95886 and 95910 provided on 11/19/20.
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 95886 is Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 95910 is Nerve conduction studies; 7-8 studies. 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 codes 95886 and 95910. Our reviewer says that the medical records do not support the billing of CPT codes 95886 and 95910 provided on 11/19/20. Our physician reviewer found the documentation submitted does not give enough description of needle electromyography and nerve conduction study as being performed. Therefore, CPT 95886 and CPT 95910 cannot be confirmed as 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 codes 95886 and 95910 have not been met. Therefore, we decided that the Plan does not have to pay for the Neurology and Neuromuscular services represented by codes 95886 and 95910 provided on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92012), gonioscopy (92020) and visual field examination (92083) provided on July 14, 2020 by an out of network (OON) provider.You asked the Plan to pay for the ophthalmic services. You say that these services were necessary.The Plan denied your request. The Plan says out-of-network services are not covered, except in limited circumstances.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 an eye exam (92012), gonioscopy (92020) and visual field examination (92083) provided on July 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a primary care office visit provided on January 28, 2021.

You asked the Plan to waive the co-payment for office visit. You say that you did not get an updated card or mail notifying you of this change in cost-sharing. The Plan denied your request. The Plan says the co-payment amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 co-payment for each primary care office visit.

You have been asked to pay $10 co-payment for office visit. Office 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 co-payment for a primary care office visit provided on January 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97530 provided on September 10, 2020.You asked the Plan to pay for code 97530. 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 as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT code 97530 is not supported in the medical record. Specifically, the records indicate the services were performed by an occupational therapy assistant in the home health setting. There is a more appropriate code for the services performed in the home health setting. Based on this information, we decided that Medicare rules for coverage of code 97530 have not been met.Therefore, we decided that the Plan does not have to pay for the therapy services represented by code 97530 provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received February 23, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that any new provider requires a comprehensive oral evaluation in order to establish care. This was a one-time issue as a result of relocating to a new state. The Plan denied your request. The Plan says there is a frequency limit for comprehensive oral evaluations of one procedure every three plan years.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the comprehensive oral evaluation when the services are medically necessary and reasonable. 

We looked at the file, and Medicare rules. The Plan limits coverage of comprehensive oral evaluations to one procedure every three plan years. The Plan has submitted evidence that you last received this procedure on November 23, 2020. When you received the procedure on February 23, 2021, the benefit was exhausted. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received February 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from November 30, 2020, through December 12, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $390 copayment each day for days 1 to 5 for Medicare-covered hospital care. You pay a $0 copayment for additional Medicare-covered days.

You have been asked to pay $1,950 ($390 copayment x 5 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from November 30, 2020, through December 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging for the enrollee.
You asked the Plan to pre-approve myocardial perfusion imaging. You say that this testing is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen stating Maximus did not apply the correct LCD criteria.
The Plan is correct in this case. Medicare has specific coverage and documentation criteria for this type of testing. The medical records provided do not show myocardial perfusion imaging was required due to inconclusive stress test or EKG results. There is no documentation of a failed exercise stress test or the inability to participate in an exercise stress test. Based on the medical records provided, the Medicare LCD coverage criteria were not met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron Tab.
You asked the Plan to pre-approve Ondansetron Tab. You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug benefit for the enrollee's diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested is not among the types which are covered by Medicare Part B unless part of a cancer chemotherapy regimen. This drug is not being requested for nausea from chemotherapy. Therefore, we decided that the Plan does not have to pre-approve Ondansetron Tab.
Benefits for Ondansetron Tab 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound care services provided from March 4, 2020, to July 31, 2020.You asked the Plan to waive the copayments for the wound care services. You say that you do not believe you owe the copayments.The Plan denied your request. The Plan says you were charged the copayments 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 $200 copayment for Outpatient Surgery. You have been asked to pay a $200 copayment for the wound care services. The wound care services fall within the Outpatient Surgery 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 copayments for wound care services provided from March 4, 2020, to July 31, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve office visits with an out-of-network provider.You asked the Plan to pre-approve out-of-network office visits. You say that this provider speaks his dialect and has been managing his psychiatric stability since the acute hospitalization. You say that this provider should be authorized to prevent future manic episodes and hospitalizations.The Plan denied your request. The Plan says that the member can safely be treated by a network provider.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 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 office visits. Our reviewer says that the documentation does not support that the plan is offering adequate care to meet the enrollee's medical and cultural/language needs through a referral to the in-network provider. Our physician reviewer found the in-network provider speaks Mandarin. It is documented that the enrollee speaks Cantonese,that enables him to understand to follow guidance with proper medication dosage regime.Although Cantonese and Mandarin have similarities, they are not mutually intelligible.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of office visits have been met.Therefore, we decided that the Plan has to pre-approve office visits with an out-of-network provider.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 27,
2020, to December 26, 2020.

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 the enrollee
required no nursing services which would be considered skilled services by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from November 27, 2020, to December 26,
2020.