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

We decided that the Plan does not have to pay for hospital services provided to the enrollee on August 22, 2019 to August 25, 2019.
You asked the Plan to pay for the hospital services. You say that hospice status was revoked, therefore the plan should be liable. The Plan denied your request. The Plan says under Medicare guidelines Original or Traditional Medicare is still responsible for payment until the start of the next month after revocation.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 18, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital services provided to the enrollee on August 22, 2019 to August 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray, first image (D0220), the additional intraoral x-rays (D0230), or the bitewing x-rays (D0274) provided on July 1, 2019.
You asked the Plan to pay for the first intraoral x-ray (D0220), the additional intraoral x-rays (D0230), and the bitewing x-rays (0274). You say that the Annual Notice of Changes shows that the x-rays are covered. You say you should not be responsible for payment. The Plan denied your request. The Plan says these are not 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 first intraoral x-ray (D0220), the additional intraoral x-rays (D0230), and the bitewing x-rays (0274) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an intraoral x-ray, first image (D0220), the additional intraoral x-rays (D0230), or the bitewing x-rays (D0274) provided on July 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Spiraxin tablets provided on June 17, 2019.
You asked the Plan to pay for self-administered drugs. You say that the doctor prescribed this medication as the standard of care for your condition, and there was no other option for your treatment at the time. The Plan denied your request. The Plan says the denial of payment for this drug is correct, because the Plan does not covers prescription drugs purchased outside of the United States.
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 pay for Spiraxin tablets provided on June 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Vyzulta 0.024% ophthalmic solution.You asked the Plan to pre-approvethis drug. You say that you are requesting reconsideration of the Plan's denialas the patient has increased eye pressure.Additionally, the patient has tried other Glaucoma eye drops, however, she has been stable with the use of Vyzulta. The Plan denied your request. The Plan says the drug was denied because the member has a medical (MA) only policy with the plan, not a Prescription Drug Plan (PDP). Therefore, drug coverage for the member is limited to Medicare Part B covered drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Vyzulta 0.024% ophthalmic solution.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray provided on September 11, 2019.You asked the Plan to pay forthe chest x-ray. You say that the enrollee was discharged on September 9, 2019 from hospice care and you believe this claim was denied in error.The Plan denied your request. The Plan says Original Medicare would be responsible for the payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe chest x-ray provided on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from August 8, 2019 to October 27, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from August 8, 2019 to October 27, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the respiratory test provided on September
24, 2019.
You asked the Plan to waive the copayment for the respiratory test. You say that you have never been charged
this before and thought it was included in the office visit. 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 for in-network Medicare-covered outpatient diagnostic procedures or tests.
You have been asked to pay a $20 copayment for the respiratory test. The respiratory test falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the
respiratory test is considered a diagnostic test.
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 respiratory test provided on September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for positive airway pressure tubing (A7037) provided on May 10, 2019.
You asked the Plan to pay for the positive airway tubing. You say that You say the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for positive airway pressure tubing (A7037) provided on May 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 7, 2019 to October 26, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is no valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 7, 2019 to October 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from July 15, 2019 to October 3, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from July 15, 2019 to October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (CPT 97110, 97140, 98943) received on July 25, 2019.

You asked the Plan to pay for the services. You say that you chose this PPO to be able to use your current chiropractor. The Plan denied your request. The Plan says this is not a covered benefit.

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 the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services (CPT 97110, 97140, 98943) received on July 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the cleaning (D1110),
the first intraoral periapical x-ray (D0220), or the additional intraoral periapical x-rays (D0230) provided on
September 25, 2019.
You asked the Plan to pay for the periodic oral evaluation (D0120), the cleaning (D1110), the first intraoral
periapical x-ray (D0220), and the additional intraoral periapical x-rays (D0230). You say that these services
should not have been denied. You say you are disabled and fully covered on medical insurance. The Plan
denied your request. The Plan says these services are not covered benefits.
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 periodic oral evaluation (D0120),
the cleaning (D1110), the first intraoral periapical x-ray (D0220), and the additional intraoral periapical x-rays
(D0230) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the periodic oral evaluation (D0120), the cleaning (D1110), the first intraoral periapical x-ray (D0220),
or the additional intraoral periapical x-rays (D0230) provided on September 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services.You asked the Plan to pre-approve SNF services. You say that the longer therapy is putoff, the longer it will take for the enrollee to recover.The Plan denied your request. The Plan says there is no complex medical condition that requires close monitoring.The Plan must follow Medicare rules. The rules say that Medicare pays for carein 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 SNF services. Our physician reviewer found that the enrollee's current level of function is maximal assist with bed mobility, dependent with Hoyer lift for transfers, dependent with lower body activities of daily living, moderate assist with upperbody ADLs, unable to stand, and non-ambulatory. The records do not support that the enrollee needs daily physical and occupational therapy. There are no noted daily skilled complex nursing needs. His current needs are custodial in nature.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF)admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a hearing aid check provided on August 5, 2019.You asked the Plan to reimburse you for the hearing aid check. The Plan denied your request. The Plan says you must use an in-network provider for hearing services.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The provider at issue in this appeal is not a network hearing services provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aid check have not been met. Therefore, we decided that the Plan does not have to reimburse you for a hearing aid check provided on August 5, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the end stage renal disease services, monthly, provided on November 30, 2018.You asked the Plan to pay forthe physician services. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for Part B benefits starting on the date of election until the last day of the month in which hospice isreceived. The Plan says that it is the provider's responsibility to verify the enrollee's coverage prior to rendering services. The Plan also says it is the provider's responsibility to know proper billing procedures for a Medicare Advantage member on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe end stage renal disease services, monthly, provided on November 30, 2018.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with altered mental status and was found to have an infection and flare of polyarthritis. She is now hemodynamically stable and afebrile. She needs assistance with activities of daily living and functional mobility and transfers. She does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She needs further therapy but does not require an intensive therapy program 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that thePlan does not have to pay for the periodontal maintenance (D4910) provided on June 3, 2019.You asked the Plan to pay for the dental service. You say that you go for a cleaning 3 times per year. You say that you switched plans on September 1, 2019.The Plan denied your request. The Plan says periodontal maintenance is not a preventive dental service. The Plan also says that periodontal maintenance is not a covered service.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, periodontal maintenance is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided on June 3, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this type of therapy will be beneficial to the enrollee's rehab and the ability to return to her independent lifestyle. The Plan denied your request. The Plan says 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 physician reviewer found that 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 33 fractions of proton beam therapy.
You asked the Plan to pre-approve proton beam therapy. You say that this is medically necessary. The Plan
denied your request. The Plan says proton beam therapy has not been demonstrated to be superior to IMRT.
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 proton beam therapy. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found to date, there is no compelling data to suggest that proton therapy is superior to or more
beneficial than intensity-modulated radiation therapy (IMRT). The generally accepted standard of care for
prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.
While comparison dose-volume histograms are provided, they are not legible, and there is no written
documentation of why the non-proton based IMRT plan is unacceptable. Therefore, proton beam therapy is not
considered medically reasonable and necessary in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan
does not have to pre-approve 33 fractions of proton beam therapy.