Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services (T1019) provided.
You asked the Plan to pay for the personal care services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says personal care services are not covered under the enrollee's Medicare benefit.
The Plan must follow Medicare rules. Medicare rules say that Custodial care is not covered. We looked at the file, the Plan's contract and Medicare rules. In this case, personal care services (T1019) were provided to the enrollee. Personal care services are considered custodial care, which includes care that helps people with activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating, personal hygiene, and supervision of special diets and medications. Custodial care and personal care services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the personal care services (T1019) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that your provide performs these services in good faith. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was 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 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 skilled nursing services provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a CPAP device and related accessories.
You asked the Plan to pre-approve the requested items. You say that the enrollee has had the current machine for 9 years and it's no longer working. The Plan denied your request. The Plan says that the records do not show a steady use of the current machine for four or more hours per night.
The Plan follows Medicare rules. Medicare rules say that positive airway pressure devices are only covered under certain medical 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 pre-approve the requested items. Our physician reviewer found that the enrollee has obstructive sleep apnea, and has been on CPAP for 19 years. The current device is 9 years old. The device display is indicating it requires replacement. The enrollee was seen on January 22, 2020, documenting continued use and benefit from CPAP. For replacement beyond the 5-year reasonable lifetime, there must be an in-person evaluation, which has taken place, but there is no requirement for a sleep test or trial period. Therefore, a replacement CPAP device is medically necessary for this enrollee. 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 requested items have been met. Therefore, we decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) device and related accessories.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 84 hours of home health aide services.
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 services are not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 the services are not medically necessary. Our physician reviewer found the enrollee has been receiving home health aide services. He has spinal stenosis, quadriplegia, and legal blindness. He has been receiving home health care for preparing meals, laundry, light housekeeping, bathing, dressing, and self-care needs. The requested home health aide services are not medically necessary, as he is receiving skilled nursing to change is catheter every two weeks. The requested 84 hours of aide services are not an appropriate frequency to treat his illness or injury. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 84 hours of home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services (T1019) provided from September 7, 2019 to September 12, 2019.
You asked the Plan to pay for the personal care services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says personal care services are not covered under the enrollee's Medicare benefit.
The Plan must follow Medicare rules. Medicare rules say that Custodial care is not covered. We looked at the file, the Plan's contract and Medicare rules. In this case, personal care services (T1019) were provided to the enrollee. Personal care services are considered custodial care, which includes care that helps people with activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating, personal hygiene, and supervision of special diets and medications. Custodial care and personal care services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the personal care services (T1019) provided from September 7, 2019 to September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services 
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 the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 01936 and 64483. Code 01936 is a column II code with a modifier indicator of 1 when billed with column I code 64483. Code 01936 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the anesthesia services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you have a shower chair that you received two years ago which you say was covered. You stated that the shower chair you received is now broken and a new one should be covered. You say that you cannot stand for very long due to your knees and back. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish provided on
January 14, 2020.
You asked the Plan to pay for the topical application of fluoride varnish. The Plan denied your request. The
Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride
varnish provided on January 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided.
You asked the Plan to waive the coinsurance for the Part B injection. You say that the injection should be considered a part of the photodynamic therapy and should be included in the specialist copayment. 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 20% coinsurance for all drugs covered under Original Medicare. You have been asked to pay $54.12 which is 20% of the allowed amount for the Part B injection. The allowed amount is $270.58. ($270.58 x 20% = $54.12). The Part B injection falls within the "Medicare Part B prescription drugs" 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 for the Part B injection provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services.
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.
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 the chiropractic services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic testing (D0431).
You asked the Plan to pay for the dental service. You say that the provider advised that they contacted your plan to confirm that this service would be approved for payment. The Plan denied your request. The Plan says adjunctive pre-diagnostic testing is not listed as 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, the adjunctive pre-diagnostic testing is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic testing (D0431).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan drops 0.0015% for the enrollee.
You asked the Plan to pre-approve the drops. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.
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 Zioptan drops 0.0015% for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services for asleep medicine consultation.You asked the Plan to pre-approve the sleep medicine consultation. You say that you do not want to go to the in-network provider because you feel the facility does not practice good hygiene and you are afraid to go due to the corona virus.The Plan denied your request. The Plan says that the services are not urgent/emergent and are available within the network. Services may be obtained from out-of-network providers only when providers of specialized services are not available in the network.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services fora sleep medicine consultation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair and lightweight manual wheelchair purchased October 8, 2019 and October 27, 2019.
You asked the Plan to pay for these items. The Plan denied your request. The Plan says that the provider does not participate in Medicare.
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who is not enrolled in the Medicare Program. The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the power wheelchair and lightweight manual wheelchair purchased October 8, 2019 and October 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lotion.
You asked the Plan to pre-approve lotion. You say that this is the best option for the enrollee. The Plan denied your request. The Plan says coverage for this medication is the responsibility of the enrollee's 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-approve lotion.
Benefits for lotion 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the regadenoson injection and sincalide injection provided on December 23, 2019 and January 2, 2020.You asked the Plan to waive the coinsurance for the regadenoson injection and sincalide injection. You say that you don't understand how the Plan can approve costs but not pay the full amount that was approved. You say that you shouldn't have to pay part of this cost.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B chemotherapy drugs, associated administration services and all other Medicare Part B drugs from an in-network provider. You have been asked to pay a total of $96.35 for the regadenoson injection and sincalide injection. The regadenoson injection and sincalide injection fall within the "Medicare Part B prescription drugs" 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 for the regadenoson injection and sincalide injection provided on December 23, 2019 and January 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says the provider is not in-network and there is no authorization for this service.
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 nurse practitioner services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for meningococcal vaccines (90620, 90734), a haemophilus
influenzae type b vaccine (90648), and administration (90471, 90472) provided on November 11, 2019.
You asked the Plan to pay for meningococcal vaccines, a haemophilus influenzae type b vaccine, and
administration. You say that these services are supported by the records. The Plan denied your request. The
Plan says these services are not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide meningococcal
vaccines, a haemophilus influenzae type b vaccine, and administration. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to meningococcal
vaccines, a haemophilus influenzae type b vaccine, and administration. Furthermore, CPT codes 90620 and
90648 are excluded from coverage. Therefore, we decided that the Plan does not have to pay for
meningococcal vaccines (90620, 90734), a haemophilus influenzae type b vaccine (90648), and administration
(90471, 90472) provided on November 11, 2019.
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 the services are medically necessary. 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 the enrollee was hospitalized for bilateral lower extremity fractures. She received oral medications and had stable vital signs. She was effectively treated for pain and a urinary tract infection. She received physical therapy in the hospital and is non-weight bearing to the lower extremities. She needed varied assistance with activities of daily living. She has no skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6750) for teeth # 22, 23, 24, 25, 26, and 27.You asked the Plan to pre-approve the dental services. You say that you need a bridge. You also say that you have a medical condition that is eating away at the enamel on your teeth.The Plan denied your request. The Plan says retainer crowns are not listed as 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, the requested retainer crowns are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6750) for teeth # 22, 23, 24, 25, 26, and 27.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on October 23, 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 the anesthesia was not required.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is insufficient documentation in the submitted case file to support that the anesthesia services were required for the rendered procedure. 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 anesthesia services rendered on October 23, 2019.