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

We decided that the Plan does not have to pay for self-administered drugs.

You asked the Plan to pay for self-administered drugs. You say that you are appealing the denial of these charges. The Plan denied your request. The Plan says the denial of payment for these drugs is correct, because self-administered drugs are not covered by Medicare Part B and coverage should be requested under your Medicare Part D prescription drug benefits.

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 self-administered drugs.

Benefits for self-administered drugs 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a cardiovascular risk assay ( 81401, 81403, 81404, 81405, 81406, 81407 and 81408) provided to the enrollee.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules state that cardiovascular assays are not covered. Medicare rules say that the appropriate place of service code must reported. In this case, this claim cannot be paid as billed due to errors in the POS code and the services billed. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for a cardiovascular risk assay ( 81401, 81403, 81404, 81405, 81406, 81407 and 81408) provided to the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical 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 procedure code 55650 is not supported.

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 55650 is vesiculectomy, any approach.

We find that CPT code 55650 is not supported in the medical record. Specifically, there is no documentation of a vesiculectomy as a separate 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 surgical services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge 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 procedure code 99239 is not supported.

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 99239 is hospital discharge day management; more than 30 minutes.

We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of 31 minutes or more of hospital discharge services spent on the enrollee. 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 hospital discharge services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that a previous advocate informed you that the facility was in-network. The Plan denied your request. The Plan says the provider in question is not in the Plan's network, and the Plan does not cover out-of-network care except in limited circumstances.

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 had network providers available who could have provided 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 the office visit (99213) provided by an out of network (OON) provider.

Your complaint about possibly receiving inaccurate information is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses provided on October 16, 2020.

You asked the Plan to pay for the eyeglasses. You say that you have never used your benefit so the allowance should be exhausted. The Plan denied your request. The Plan says the optical frame allowance has been exhausted.

Medicare generally does not cover routine vision and eyewear services. However, 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. 

We looked at the file and the Plan's rules. The file shows that the total cost of the eyeglasses was $469. The Plan paid $150 based on your plan benefits. You are responsible for any amount over the Plan allowance. Therefore, we decided that the Plan does not have to further pay for the eyeglasses provided on October 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87500, 87798, 87799, 87640, 87653, 87482) provided October 9, 2020.

You asked the Plan to pay for laboratory services. You say that these services were provided as ordered by the treating physician. The Plan denied your request. The Plan says the services are non-covered screening tests.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory services (87500, 87798, 87799, 87640, 87653, 87482) provided October 9, 2020.
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 this admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and 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 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 complexity of the nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a colectomy for colon cancer. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medicare coverage criteria are not met. 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99285, 96374, 70450, 93005) provided on January 31, 2019.

You asked the Plan to pay for an emergency room visit. You say that this was filed timely. The Plan denied your request. The Plan says this was filed more than a year after the date of service.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for an emergency room visit was not filed until July 8, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99285, 96374, 70450, 93005) provided on January 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on August 13, 2020.

You asked the Plan to pay for the ambulance services. You say that you did not think you were hurt so you refused the transport. The Plan denied your request. The Plan says ambulance services without a transport are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on August 13, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance services provided on August 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01230) and an injection with ultrasound guidance (64450, 76942) provided September 29, 2020.

You asked the Plan to pay for anesthesia services and an injection with ultrasound guidance. You say that the member's hospice status was revoked September 27, 2020. The Plan denied your request. The Plan says during the election, fee-for- service Medicare also covers attending physician services and all care unrelated to the terminal illness starting on the date of the Hospice election until the first day of the month following the month in which Hospice is revoked or discharged.

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 September 27, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for anesthesia services (01230) and an injection with ultrasound guidance (64450, 76942) provided September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services.

You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says this service requires authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for ophthalmological services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF currently. The patient's medical status given her pleural effusions and increasing creatinine continue to require acute care monitoring and management prior to transferring to a rehabilitation program. While the patient may benefit and participate in multiple therapies, the patient's functional level does not appear to be able to tolerate this therapy in an intensive rehabilitation therapy program provided 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.

You asked the Plan to pre-approve skilled nursing facility services. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when four factors 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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records show you do not require skilled nursing or therapy services on a daily basis. Your do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of inpatient skilled nursing facility care.

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 SNF care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the documentation does not support that skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse is required to safely and effectively provide medically necessary and reasonable treatment in a skilled nursing facility. The patient does not have complex wound care or other skilled nursing needs that require a skilled nursing facility stay. The patient 's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a skilled nursing facility. Additionally, skilled services are not needed on a daily basis or as practical matter in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 21, 2020.

You asked the Plan to pay for the ambulance services. You say that you did not request this service. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on February 21, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on October 22, 2019.

You asked the Plan to waive the copayment for an emergency room visit. You say that you would like to appeal these charges. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $90 copayment for emergency care/emergency room visits. 

You have been asked to pay a $90 copayment for an emergency room visit. The correct copayment has been applied to the services that were provided. An emergency room visit falls within the emergency care/emergency room visits 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 an emergency room visit provided by a participating provider on October 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neuromuscular stimulator provided on September 29, 2020.

You asked the Plan to pre-approve the neuromuscular stimulator, electronic shock unit (E0745). You say that the enrollee needs an NMES for thoracic pain. The Plan denied your request. The Plan says a neuromuscular stimulator is not covered for back pain.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the neuromuscular stimulator, electronic shock unit (E0745). Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found it has not been demonstrated that the enrollee demonstrates brisk muscle contraction to NMES and has sensoryperception electrical stimulation sufficient for muscle contraction, has muscle and joint stability for weight bearing at the upper and lower extremities and can demonstrate balance and control to maintain an upright support posture independently, and can transfer independently and can demonstrate independent standing tolerance for at least 3 minutes. 

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 neuromuscular stimulator, electronic shock unit (E0745) have not been met. Therefore, we decided that the Plan does not have to pre-approve the neuromuscular stimulator provided on September 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CustomFlex Artificial Iris.

You asked the Plan to pre-approve a CustomFlex Artificial Iris. You say that this surgery is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

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 a CustomFlex Artificial Iris. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer states that the use of an artificial iris is considered investigational at this time and is not covered by Medicare.

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 Custom Flex Artificial Iris have not been met. Therefore, we decided that the Plan does not have to pre-approve a CustomFlex Artificial Iris.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent annual wellness visits (G0439) provided October 6, 2020.

You asked the Plan to pay for subsequent annual wellness visits. You say that being that this was a new doctor you thought the plan asked him to do it. You were told if you don't do a wellness check-up, the insurance company has a right to deny you service. The Plan denied your request. The Plan says the service exceeds the benefit frequency limitation.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. 

Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for subsequent annual wellness visits (G0439) provided October 6, 2020.