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

We decided that the Plan does not have to payforthe medical services provided on August 8, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the provider does not need authorization.The Plan denied your request. The Plan says non-participating providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. 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 forthe medical services provided on August 8, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora scooter purchased on September 11, 2019 from a non-Medicare provider.You asked the Plan to pay for the scooter. You say that you purchased the scooter from this provider because it was cheaper than the local vendors.The Plan denied your request. The Plan says Progress Mobility does not except any type of insurance and is excluded from Medicare.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scooter have not been met. You are financially responsible for services when they see providers that are excluded from the Medicare program.Therefore, we decided that the Plan does not have to pay fora scooter purchased on September 11, 2019 from a non-Medicare provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on September 24, 2019.You asked the Plan to pay for the surgical pathology services.The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 servicesat 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 surgical pathology services provided on September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the osteogenesis stimulator provided on September 29, 2019.You asked the Plan to waive the coinsurance for the osteogenesis stimulator. You say that you were not aware there would be a cost for the equipment.The Plan denied your request. The Plan says that the claim processed 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 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the osteogenesis stimulator. The osteogenesis stimulator falls within the durable medical equipment (DME) and related supplies 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 forthe osteogenesis stimulator provided on September 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided February 23 to February 24, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary.The Plan denied your request. The Plan says coverage criteria was not met.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 record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.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 forthe acute inpatient hospital care provided February 23 to February 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a polysomnography/sleep study for the enrollee.
You asked the Plan to pre-approve the study. You say that this is medically necessary, as the enrollee is unable to sleep due to pain. The Plan denied your request. The Plan says these studies cannot be performed to diagnose chronic lung disease.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 study. Our reviewer says that the requested study is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have any snoring or choking during sleep. There is no evidence of excessive daytime sleepiness. Based on the medical records provided, the enrollee does not meet the criteria for this study.
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 study have not been met. Therefore, we decided that the Plan does not have to pre-approve a polysomnography/sleep study for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for batteries delivery fee provided on October 8, 2019 by an out-of-network provider.You asked the Plan to pay for the DME. You say that you obtained two replacement batteries for your power wheelchair.The Plan denied your request. The Plan says you had a prior authorization in place for the batteries and submitted an invoice with your request. The Plan states the claim processed and paid; however, the claim for delivery fees are not payable by Medicare.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. You were reimbursed the Medicare allowable of $136.46 of the $180 charged per the DME fee schedule for the purchased UI sealed lead acid batteries. Any payment over the Medicare allowable is not payable by Medicare nor the health plan. In addition, delivery fees, shipping and handling in the amount of $20 are not covered by Medicare and not payable by the health plan.Therefore, we decided that the Plan does not have to pay for batteries delivery fee provided on October 8, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvewheelchair and accessories, for the enrollee.You asked the Plan to pre-approvethe DME. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says there is no need for a new wheelchair.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DMEhave not been met. There is no need for a new wheelchair. The wheelchair is same as previously supplied wheelchair which was deliveredto member in June of 2019. New request is for manual wheelchair and no explanation or rationale as to why the same equipment is being requested and why the previous wheelchair no longer is acceptable.Therefore, we decided that the Plan does not have to pre-approvewheelchair and accessories, for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay fortherapeutic injections (96374 and 96375) provided on August 17, 2019.You asked the Plan to pay forthe injections. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation does not support the services 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.In this case, the CPT Code Manual definition of code 96374 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug.The CPT code manual definition of code 96375 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure).We asked our coder 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 injections. Our reviewer says that CPT code 96374 does not meet criteria for billing or reimbursement consideration. There is no documentation of how the drugs were administered, therefore this service cannot be verified. Our reviewer found CPT code 96375 does not meet criteria for billing or reimbursement consideration. CPT 96375 is an add-on code and requires the primary service code to be eligible for reimbursement. In this case, primary code 96374 was denied so CPT 96375 is not eligiblefor separate reimbursement.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met.Therefore, we decided that the Plan does not have to pay fortherapeutic injections (96374 and 96375) provided on August 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveZarxio (Q5101) and Pegfilgrastim (J2505).You asked the Plan to pre-approveZarxio and Pegfilgrastim. You say that the medications are necessary.The Plan denied your request. The Plan says they are not responsible for covered routine costs associated with clinical trials.The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.In this case, you asked the Plan to pre-approve Zarxio and Pegfilgrastim as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials.Therefore, we decided that the Plan does not have to pre-approveZarxio (Q5101) and Pegfilgrastim (J2505).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services, medical examination provided on June 18, 2019.You asked the Plan to pay for the ophthalmological services, medical examination. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 ophthalmological services, medical examination provided on June 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 13, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 services at issue in this appeal. 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 forthe medical services provided to the enrollee by an out-of-network provider on November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foroxygen concentrator (E1390) rented on October 30, 2019 from an out-of-network provider.You asked the Plan to waive the coinsurance forthe DME. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received anoxygen concentrator (E1390) rented on October 30, 2019 from an out-of-network provider. The claim was processed correctly based on you out-of-network benefits in accordance to your EOC, which states, Medicare-covered Out-of-Network DME will be covered at 30% which was the amount that was reimbursed to you. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance foroxygen concentrator (E1390) rented on October 30, 2019 from an out-of-network provider
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided from November 5, 2019 through November 7, 2019.You asked the Plan to waive the copayment for the ER visit. You say that you were admitted. You say that you were informed the copayment was waived if you were admitted. 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 to be an inpatient, your provider must write an order to admit you formally as an inpatient of the hospital. Even if you stay in the hospital overnight, you might still be considered an "outpatient."Your contract with the Plan clearly says that you must pay a $100 copayment for each Medicare-covered emergency room visit.You have been asked to pay a $100 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The records show that you were admitted to outpatient observation. 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 November 5, 2019 through November 7, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe  gingival irrigation (D4921) and the localized delivery of antimicrobial agents (D4381 x 2) provided on November 21, 2019.You asked the Plan to pay forthe gingival irrigation and the localized delivery of antimicrobial agents. You say that the regular cleaning should be covered. You say that a plan representative advised on December 16, 2019 that the cleaning was not covered because it was received on the same day as another cleaning. You say that you cannot find this information in your benefit packet. You also say that the plan representative could not tell you where to find this information.The Plan denied your request. The Plan says gingival irrigation and the localized delivery of antimicrobial agents are not listed as covered services.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 gingival irrigation and localized deliver of antimicrobial agents are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe  gingival irrigation (D4921) and the localized delivery of antimicrobial agents (D4381 x 2) provided on November 21, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forEmergency Room services provided September 10 to September 12, 2019.You asked the Plan to waive the copayment forthe emergency room services. You say that you were kept overnight so the inpatient copayment should be applied.The Plan denied your request. The Plan says the correct copayment was applied because you were not admitted as an inpatient.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 $120 copayment for Emergency Care. You have been asked to pay a $120 copayment for the emergency room services. The emergency room services fall within the Emergency 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 forEmergency Room services provided September 10 to September 12, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay  for the ambulance services. You say that your CO2 detectorwent off in the middle of the night and an ambulance came automatically. You say that the ambulance checked you out without your permission and you do not feel like the claim should be your liability.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 June 1, 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 forthe ambulance services.
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 admission to a SNF.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 skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a tracheostomy tube, new enteral feedings, complex wound care, IV medications or other SNF level skilled nursing need. The enrollee does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee is already transferring standby assist and ambulating 150 feet. It is unclear why he needs speech therapy. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.