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

We decided that the Plan does not have to waive the cost share for a vision exam and refraction services provided on November 5, 2019.You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct.The Plan denied your request. The Plan says this cost share is based on the claim submitted by the provider and the Plan contract agreement regarding what is covered under vision services. Medicare generally does not cover routine vision and eyewear services. Medicare does not cover refraction services. 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 contract states that a vision exam is $45. The Plan contract states that refraction services are not covered. Therefore, we decided that the Plan does not have to waive the cost share for a vision exam and refraction services provided on November 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee x-ray (73564), transportation of portable x-ray equipment and personnel to home or nursing home (R0070), and set-up of portable x-ray equipment (Q0092) provided on October 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the knee x-ray, transportation of portable x-ray equipment and personnel, and set-up of portable x-ray equipment. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says prior authorization was not requested or received and the services were not emergent in nature. Therefore, coverage criteria has not been met.
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 a knee x-ray (73564), transportation of portable x-ray equipment and personnel to home or nursing home (R0070), and set-up of portable x-ray equipment (Q0092) provided on October 23, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveZytiga tablets.You asked the Plan to pre-approveZytiga tablets. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Zytiga tablets are not covered under the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveZytiga tablets.Benefits for Zytiga tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on September 25, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee on September 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. 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 lab 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 OON services. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 9, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you received oral medications and insulin and had stable vital signs. You received physical, occupational, and speech therapy and are independent with functional mobility. You need supervision to modified independent level for activities of daily living. You have no skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a telephone alert system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says telephone alert systems are not covered, because they are considered emergency communication systems, and do not service a diagnostic or therapeutic purpose.
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 a telephone alert system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for office visit. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring provider is also out-of-network with the Plan.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 forthe medical services provided on September 9, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on December 5, 2019.You asked the Plan to waive the copayment for laboratory services. You say that these tests are necessary for your doctor to know what medication you should be on. You say that you don't see a reason 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 $10 per day for Medicare-covered laboratory tests.You have been asked to pay a $10 copayment for the laboratory services. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for laboratory services provided on December 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira (J0135).You asked the Plan to pre-approveHumira. You say that this is medically necessary.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveHumira (J0135).Benefits for Humiramay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

Explanation of decision
We decided that the Plan does not have to waive the copayment for physical therapy provided from September 4, 2019 through September 17, 2019.
You asked the Plan to waive the copayment for physical therapy. You say that the physical therapy was unnecessary. You say that you should be reimbursed. The Plan denied your request. The Plan says the copayments 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 $40 copayment for Medicare-covered physical therapy. You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $200 ($40/visit x 5 visits = $200). Physical therapy falls within the "Outpatient rehabilitation 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 waive the copayment for physical therapy provided from September 4, 2019 through September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection of onabotulinumtoxina (Botox) provided on October 16, 2019.
You asked the Plan to pay for Botox injection. You say that you were not feeling well on this date of service and were in a lot of pain. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this procedure was cosmetic in nature and is not covered by Medicare.
The Plan follows Medicare rules. Medicare rules say that Botox injections are only covered for certain specific indications. 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 Botox injection. Our reviewer says that this procedure does not meet the Medicare criteria for coverage. Our physician reviewer found the documentation submitted does not support that this was performed for any of the Medicare covered indications, and therefore this Botox injection is not considered medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox injection have not been met. Therefore, we decided that the Plan does not have to pay for an injection of onabotulinumtoxina (Botox) provided on October 16, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from September 11, 2019 through September 24, 2019.
You asked the Plan to waive the copayment for physical therapy. You say that you are wondering why you are being billed for services while you were an inpatient. The Plan denied your request. The Plan says the copayments 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 $20 copayment for Medicare-covered physical therapy. You have been asked to pay a $20 copayment for each physical therapy visit. The total amount you owe is $220 ($20/visit x 11 visits = $220). The physical therapy falls within the "Inpatient stay: Covered services received in a hospital or SNF during a non-covered inpatient stay" 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 physical therapy provided from September 11, 2019 through September 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapist.
You asked the Plan to pre-approve these services. You say that you need to go to a location closer to your home. The Plan denied your request. The Plan says the services are available from 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 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 confirmed that there is a network provider available that is located the same distance from your home as the requested provider. 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 a referral to an out-of-network physical therapist.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (95940) and electrodes (A4556 and A4557) provided on June 7, 2019.
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the place of service billed is not appropriate for CPT code 95940 and CPT codes A4556 and A4557 are bundled services.
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 codes 95940, A4556 and A4557 are not supported in the record. Specifically, this claim was submitted with place of service code 15. Per the LCD, this is not an appropriate place of service for the service billed. Additionally, CPT codes A4556 and A4557 are bundled codes and not eligible for separate reimbursement. Based on this information, we decided that Medicare rules for coverage of the continuous intraoperative neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (95940) and electrodes (A4556 and A4557) provided on June 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. 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 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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. The enrollee may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. The enrollee will not be able to participate and remember the skills learned in PT and OT. IRF admission is not medically necessary based on the enrollee's current functional cognitive status and medical stability. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the typhoid vaccine you received on November 22, 2019.
You asked the Plan to pay for the vaccine. You say that you thought the service was covered in-network. The Plan denied your request. The Plan says the service is not covered under your medical plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the typhoid vaccine you received on November 22, 2019.
Benefits for the vaccine 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 pay for physiological support for harvesting of organs provided to the enrollee on September 6, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is not a covered code.
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 01990 is "physiological support for harvesting of organ(s) from a brain-death patient." We find that CPT code 01990 is not supported in the medical record. Specifically, Medicare does cover this code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for physiological support for harvesting of organs provided to the enrollee on September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 7, 2019.
You asked the Plan to pay for the 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 for the medical services provided to the enrollee by an out-of-network provider on November 7, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 12, 2019 to September 23, 2019.
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim was not submitted with the correct type of bill per Medicare payment guidelines.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. The rules say the Type of Bill is a required data element needed to submit a claim under home health PPS. This 4-digit code gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit indicates the sequence of this bill in this particular episode of care. The types of bill accepted for HH PPS requests for anticipated payment are either 7, 8, or 9 as defined above. HHAs must submit HH PPS claims with the 4th digit of "9." Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 12, 2019 to September 23, 2019.