Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the wheelchair rental provided on October 21, 2019.You asked the Plan to reimburse you for the wheelchair rental. You say that you had a prescription but could not find a supplier in your area that accepted insurance.The Plan denied your request. The Plan says the supplier does not participate in Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or provider who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to reimburse you for the wheelchair rental provided on October 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive oral exam (D0150) and cleaning (D1110) provided November 26, 2019.You asked the Plan to pay forthe dental services. You say that you were told by a plan representative that his provider was in network and do not feel that you should have to pay the bill sent from the provider. The Plan denied your request. The Plan says this claim was processed correctly as the provider is not a part of the DenteMax group of dentists.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 $60 copayment for out of network Medicare covered dental services. The health plan contract also says that if you choose to go to a dentist other than a DenteMax dentist, you may pay more. The dentist can bill you for additional costs. You have been asked to pay $85 for the dental services. the dental services fall within the Dental services 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 pay forcomprehensive oral exam (D0150) and cleaning (D1110) provided November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on August 14, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient lab work. You say that you were unaware that you needed to go to Quest Diagnostics for your tests.The Plan denied your request. The Plan says no prior authorization was obtained for these services.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 foroutpatient lab work provided on August 14, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultraviolet light therapy system provided on May 5, 2017.You asked the Plan to pay forthe ultraviolet light therapy system (E0691). You say that the Plan should pay this claim.The Plan denied your request. The Plan says rules for telehealth services were not met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe ultraviolet light therapy system provided on May 5, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora handheld shower head, two grab bars for the bath, a shower chair, and a stair lift provided to you on January 29, 2019.You asked the Plan to pay for the handheld shower head, two grab bars for the bath, a shower chair, and a stair lift. You say that you need these items to be able to function.The Plan denied your request. The Plan says these items do not meet the Medicare definition of durable medical equipment and therefore are not covered.The Plan must follow Medicare rules. Medicare rules say that these items are not covered because they are not primarily medical in nature. While these items may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pay fora handheld shower head, two grab bars for the bath, a shower chair, and a stair lift provided to you on January 29, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from March 6, 2019 to July 9, 2019.
You asked the Plan to pay for home infusion therapy. You say that this was medically necessary. The Plan denied your request. The Plan says this code is not payable by Medicare.
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 S9328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from March 6, 2019 to July 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services
You asked the Plan to pre-approve IRF care. You say that inpatient rehab is the only level of care that will be able to restore the enrollee's prior level of function. The Plan denied your request. The Plan says there is no medical complexity to support rehab supervision three times a week, or an intensive rehab therapy program.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our physician reviewer found that the enrollee is ambulating with a rolling walker and no loss of balance. She is at a moderate assist level for lower body dressing, bed mobility and toilet transfers. She is at contact guard assist for upper body bathing, and upper extremity dressing. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that her medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on September 6, 2019 by an out of network (OON) provider.You asked the Plan to pay for lab services. You say that the member was never informed of where her analysis would be sent.The Plan denied your request. The Plan says the ordering provider is out-of-network. The Plan says that no prior authorization was obtained for these services.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 lab services provided on September 6, 2019 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out-of-network services. You say that your spinal stenosis makes it necessary to have stem cells as surgery could be disastrous. The Plan denied your request. The Plan says your care can be managed by in-network providers.
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 file shows that office visit were requested for stem cell injections of the knee. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide orthopedic services. The requested use of the stem cell treatments is not FDA-approved for your condition. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approve orthopedic services to be provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room Services (99284) provided on July 7, 2019.You asked the Plan to pay for the Emergency Room services. You say that services were medically necessary and correctly billed.The Plan denied your request. The Plan says 99284 is 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 99284 is Emergency Room Care, Level 4.We find that CPT code 99284 is not supported in the medical record. Specifically, the record shows a diagnosis of malaise. Records do not show shortness of breath. The medical decision making was low to moderate complexity. Therefore, the documentation does not support the billing of CPT 99284, which requires that the history and examination be detailed and that the medical decision making be of moderate complexity. Based on this information, we decided that Medicare rules for coverage of the Emergency Room services have not been met.Therefore, we decided that the Plan does not have to pay for Emergency Room Services (99284) provided on July 7, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for an office visit (99215) provided on October 15, 2019.You asked the Plan to hold you harmless for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this service is not payable for the provider's specialty.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.The Plan states that this provider is a contract provider. The file does not show that the plan provided notice that the office visit would not be covered. Under Medicare rules, this means the office visit is considered approved. Additionally, the Plan did not forward sufficient information to substantiate their denial. Therefore, we decided that the Plan has to hold you harmless for an office visit (99215) provided on October 15, 2019. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you believe the claim for the ambulance service should be covered. 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 October 9, 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 the ambulance services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Xgeva.You asked the Plan to pre-approve Xgeva. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says that the Plan's step therapy criteria have not been met.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. Therefore, we decided that the Plan has to pre-approve Xgeva.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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe EKG provided on October 22, 2019.You asked the Plan to waive the copayment forthe EKG. You say that you thought the EKG was a part of your health visit that has no copayments. You had this service years ago and was not charged. 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 $20 copayment in a physician's office. You have been asked to pay a $16.48 which is less than the standard copayment for the EKG. The EKG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you havebeen 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 EKG provided on October 22, 2019.Our decision is only about the 2019 services. If you have any questions about prior years billing, please contact the plan directly
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.The Plan must follow Medicare rules.The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the enrollee is with a history of Parkinson's disease who presented to the hospital on 3/3/2020 with sudden onset of right upper and lower extremity weakness, difficulty walking, change in speech pattern, and dysarthria. She states these changes were of new and sudden onset. She was evaluated for suspected stroke. Seen by neurology, physical therapy,and speech therapy. Per progress note on 3/9/2020 the staff observed that the enrollee is not able to bathe herself, not able to cut her food, and has difficulty feeding herself. The enrollee is right handed but due to the weakness of the right arm, she is feeding herself with her left side. She is unable to comb her hair or brush her hair independently.The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay forthe ambulance services provided on October 18, 2019.You asked the Plan to pay forthe second transport. You say that there were two transports on the same day.The Plan denied your request. The Plan says that the second claim is a duplicate.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Medicare rules say that claims must be submitted with the appropriate medical record information. The rules also state health plans must make diligent efforts to forward in formation to the IRE. The medical records clearly show that the enrollee had two separate transport services on the same day at different times of the day.Based on this information, we decided that Medicare rules for coverage of the second transport, have been met.Therefore, we decided that the Plan has to pay forthe ambulance services provided on October 18, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enteral formula for the enrollee.
You asked the Plan to pre-approve Enteral formula. You say that the enrollee is unable to recognize the need for food and without tube feedings she will have failure to thrive. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.
The Plan follows Medicare rules. Medicare rules say that enteral formula is covered for the above indication. 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 Enteral formula. Our reviewer says that that Enteral formula is not reasonable and necessary for the enrollee in this case. Documentation does not support the enrollee has a disease affecting the small bowel or impairment with digestive tract. Without the support of the documentation, medical necessity is not determined. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for coverage of Enteral formula. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Enteral formula have not been met. Therefore, we decided that the Plan does not have to pre-approve Enteral formula for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient lab tests provided on July 1, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient lab tests. You say that you did not know you needed a referral to save a life.The Plan denied your request. The Plan says no prior authorization was obtained for these services.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 foroutpatient lab tests provided on July 1, 2019 by an out of network (OON) provider.