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

We decided that the Plan does not have to pay forthe outpatient hospital services provided on March 5, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe outpatient hospital services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the servicesprovided 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 has network providers available whocan 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 outpatient hospital services provided on March 5, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient therapy provided from November 25, 2019 through November 30, 2019.
You asked the Plan to waive the copayment for outpatient therapy. You say that you requested for the provider to submit a request for coverage. You say that the last week of rehabilitation should be covered. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $35 copayment for each covered physical, occupational and speech therapy visit from an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (98940, 99203) provided from November 11, 2019, to November 18, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says you are responsible for payment. The rules say a plan must disclose to its enrollees in clear, accurate terms all costsharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for each Medicare-covered chiropractic visit. The rules also say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.Review of the files shows that you had three chiropractic office visits for Medicare-covered services. You have been asked to pay a $20 copayment for each visit. The services fall within the chiropractic 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.Additionally, you received chiropractic services during these visits that are not covered by Medicare (CPT 99203). The records show that these services are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the chiropractic services (98940, 99203) provided from November 11, 2019, to November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on February 28, 2020.You asked the Plan to waive the copayment for the specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received a specialist visit on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 $45 copayment for each Medicare-covered specialist visit. We looked at the file, the Plan's contract and Medicare rules. The file shows that you had a specialist visit on February 28, 2020. You have been asked to pay a $45 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner 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 the specialist visit provided on February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forvision services provided on January 15, 2020 by an out-of-network provider.You asked the Plan to pay forvision services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you do not have out-of-network benefits.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 forvision services provided on January 15, 2020 by an out-of-network provider.
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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, you are mostly total/maximum assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy may be more appropriate. It is not clear you would be able to fully benefit and/or participate in an IRF 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 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: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from January 1, 2020 to January 18, 2020.
You asked the Plan to pay for the SNF services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services were paid correctly.
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. In this case, the Plan says the claim processed correctly. The Plan has not provided any documentation showing that the claim processed correctly per Medicare guidelines. The Plan has not substantiated their reasoning for denial. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from January 1, 2020 to January 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy for the enrollee.You asked the Plan to pre-approve this drug. You say that this is needed for the treatment of the enrollee's migraine.The Plan denied your request. The Plan says that this is not covered under Part B.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-approve Ubrelvy for the enrollee.Benefits for this drug 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nurse visits (G0299, G0300).
You asked the Plan to pre-approve home health nurse visits. You say that you need to have your blood drawn at home. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health nurse visits. Our reviewer says that the criteria for home health nurse visits has not been met. Our physician reviewer found the documentation does not reveal evidence of complex wound care, new enteral feedings or other skilled nursing need therefore the request for skilled nursing for venipuncture is not 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 home health nurse visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health nurse visits (G0299, G0300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 27, 2020.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 27, 2020.
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 fo rlaboratory services. You say that annual wellness visits are free.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $5 copayment for diagnostic lab services and diagnostic procedures and tests.The enrollee has been asked to pay a $5 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. 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 copayment for laboratory services provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (99100, 99140) provided on December 5, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in the primary procedure.The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Procedure codes99100and 99140areassigned a status indicator of "B" under the Physician Fee Schedule, which means that these are bundled services. Payment for these servicesis bundled into payment for other services. No separate payment can be made for the anesthesia services. 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 forthe anesthesia services (99100, 99140) provided on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe adjustable bed purchased on January 2, 2020.You asked the Plan to reimburse you forthe adjustable bed. You say that you had a hospital bed that was too slowThe Plan denied your request. The Plan says you obtained a bed from a provider who does not participate with Medicare and only hospital beds are covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met:1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an ordinary bed; or2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration.  Pillows or wedges must have been considered and ruled out; or 4. The patient requires traction equipment, which can only be attached to a hospital bed.The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. We looked at the file and Medicare rules. The item at issue in this appeal was provided by a provider not certified by Medicare. The physician order was for an electronic hospital bed. Only hospital beds are covered by Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of the adjustable bed have not been met.Therefore, we decided that the Plan does not have to reimburse you forthe adjustable bed purchased on January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordetermination of refractivestate (92015) provided on August 8, 2019.You asked the Plan to pay forthe eye refraction. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says Original Medicare does not cover routine eye exams (eye refractions) for eyeglasses/contacts. The plan states the provider has been informed to submit the claim to your supplemental vision plan.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Original Medicare does not cover routine eye exams (eye refractions) for eyeglasses/contacts.Therefore, we decided that the Plan does not have to pay fordetermination of refractive state (92015) provided on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for face mask interface, replacement for full face mask, each (A7031) and respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) (E0470) provided to the enrollee on August 20, 2019.
You asked the Plan to pay for the oxygen equipment. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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 oxygen equipment have not been met. Healthcare Common Procedure Coding System (HCPCS) code E0470 RR KX KH (1 Unit) remains not supported. The documentation submitted did not include a valid physician order. In addition, the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. Therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code A7031 NU KX (3 Units) remains not supported. The documentation submitted did not support the units billed; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met.
Therefore, we decided that the Plan does not have to pay for face mask interface, replacement for full face mask, each (A7031) and respiratory assist device, bi-level pressure capability, without backup rate feature,
used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) (E0470) provided to the enrollee on August 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250).
You asked the Plan to pre-approve a CT scan of the chest. You say that the service is 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. Medicare rules say that CT scans are covered only when they are medically necessary. 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 a CT scan of the chest. Our reviewer says that the service is not medically necessary. Our physician reviewer found according to the coverage criteria, guidelines support a three-week trial of antihistamine and decongestant treatment prior to considering a chest CT for the evaluation of a cough. Guidelines support a recent (during the last three weeks) trial of steroids prior to considering a chest CT for the evaluation of a cough. The clinical information provided does not describe this trial. Guidelines support a three-week discontinuation of all medications known to cause a cough (e.g. ACE inhibitors) prior to considering a chest CT for the evaluation of a cough. The clinical information provided does not meet this criterion, as well. The review has determined that the requested CT scan of the chest is not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the chest have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health services (90837) provided February 4 to December 19, 2019.You asked the Plan to pay forthe outpatient mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says the provider does not participate in the Medicare program and is ineligible for payment.The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that the provider has opted out of Medicare. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pay foroutpatient mental health services (90837) provided February 4 to December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from January 6, 2020 to February 6, 2020.You asked the Plan to pay for all services provided. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says those services not related to manual manipulation of the spine are not covered.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.The records show that some of the services denied are not related to manual manipulation of the spine.Any services not covered by the Plan or by Medicare are your financial responsibility. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from January 6, 2020 to February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on October 11, 2019.You asked the Plan to pay forthe physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services were provided outside of the United States and are not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members the benefitsoffered under the plan including applicable conditions and limitations.We looked at the file, the Plan's contract and Medicare rules. Medicare says services furnished outside of the United States are not covered.Therefore, we decided that the Plan does not have to pay forthe physician services provided on October 11, 2019.