Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam you received on October 22, 2019. You asked the Plan to pay for the exam. You say that this should be considered an exam. The Plan denied your request. The Plan says only two oral exams are covered per year. 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 services are subject to a benefit limitation. The plan covers only two oral exams per calendar year. The records show that you received covered oral exams on April 9, 2019, and July 2, 2019. This is your third exam of the 2019 calendar year, which exceeds the benefit limit. Therefore, we decided that the Plan does not have to pay for the oral exam you received on October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you require IRF care in order to return to your baseline of function. The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 18, 2019.
You asked the Plan to pay for the ambulance services to and from a doctor appointment. You say that the Plan should pay the claims. 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 pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care supplies provided on September 26, 2019.
You asked the Plan to pay for collagen dressing (A6021) and specialty absorptive dressing (A6252). 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 and 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 for the
wound care supplies provided on September 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 73630) provided on October 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.
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 73630 is "Radiologic examination, foot; complete, minimum of 3 views". We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of CPT code 73630 is not supported by the records provided. Our physician reviewer found that while the October 28, 2019, note indicates that x-rays were acquired on October 28, 2019, these x-rays have not been submitted for review. Because the October 28, 2019, note is so similar to the October 3, 2019, note, it is unclear if the October 28, 2019, documentation is new or a cut and paste of the October 3, 2019, documentation. Without dated x-rays from October 28, 2019, the documentation does not support the billing of CPT 73630 on October 28, 2019. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 73630) provided on October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator provided on September 30, 2019 by an out of network provider
You asked the Plan to pay for the oxygen concentrator. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior 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 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 the oxygen concentrator provided on September 30, 2019 by an out of network provider,
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the rental of a Airway Clearance System 
You asked the Plan to pre-approve the respiratory vest. You say that because the requested item is a specialty item, the Plan's network providers cannot provide the same services or therapy as the Airway Clearance System. The Plan denied your request. The Plan says the requested services can be provided in 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 items/services at issue in this appeal, We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the rental of a  Airway Clearance System
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 30, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you cannot afford this. The Plan denied your request. The Plan says cost-sharing is a contractual obligation of the plan and cannot be waived.
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 $195 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $195 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip 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 ambulance transport provided on November 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the lancets purchased from on November 13,
2019.
You asked the Plan to reimburse you for the lancets. You say that you needed the lancets to monitor your blood
sugar level. The Plan denied your request. The Plan says the items at issue in this appeal were purchased from a
provider not certified by Medicare.
The Plan must follow Medicare rules. 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.
Payment cannot be made for items purchased from this provider because this provider is not a medical provider
and is not enrolled in Medicare. Therefore, we decided that the Plan does not have to reimburse you for the
lancets purchased on November 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the rendered services are not a covered benefit.
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 the laboratory services provided on July 16, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on September 18, 2019.
You asked the Plan to pay for the hearing aids. You say that you chose to buy hearing aids because the companies you par with do not offer the same quality of hearing aids nor do they offer same day service and individual attention. The Plan denied your request. The Plan says the hearing benefit is not covered if the services are not ordered through the designated vendors.
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. The Plan pays for hearing aids only Hearing aids must be purchased through certain healthcare. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids purchased on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on
October 24, 2019.
You asked the Plan to pay for the knee orthoses (L1851) and suspension sleeves (L2397). You say that the
orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services
have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items ordered following the noncovered visit are likewise
noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension
sleeves provided on October 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on December 2, 2019 to December 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the enrollee required skilled services, and would not have progressed to her current level of function. The Plan denied your request. The Plan says authorization is required, and was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on December 2, 2019 to December 31, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit (99215) provided on September 9, 2019.
You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 99215 is not supported in the record. Specifically, this claim has been submitted with diagnosis code R53.0. Per ICD-10, this diagnosis code includes a "code first" note, meaning, the underlying condition diagnosis code should always be coded before R53.0. Based on this information, we decided that Medicare rules for coverage of the outpatient visit have not been met. Therefore, we decided that the Plan does not have to pay for an outpatient visit (99215) provided on September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the face-down positioning table (coded as E1399 provided to the enrollee on June 9, 2019. You asked the Plan to pay for the DME. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says CMS has confirmed that these devices are statutorily non covered because they do not fall within a Medicare benefit category. The Plan states that these types of devices are considered "precautionary devices" and also can be used for purposes other than the treatment of an illness or injury.
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 DME have not been met. We reviewed the enrollee's records and they show that the enrollee underwent eye surgery. The record sent by their provider indicates that the enrollee underwent eye surgery and their provider recommended this device as a precaution to prevent complications following the enrollee's surgery. Therefore, we decided that the Plan does not have to pay for the face-down positioning table (coded as E1399 provided to the enrollee on June 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on November 1, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says there is no documentation of a prior authorization, and services are available in-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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the podiatry services provided on November 1, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has only has to pay for inpatient psychiatric hospital services provided August 23, 2019.
You asked the Plan to pay for inpatient psychiatric hospital services provided to the enrollee. You say that the Plan paid this claim and then requested a refund. You state that these services were provided and should be covered by the Plan. The Plan denied your request. The Plan says that a recent review of paid claims has determined the claim was paid incorrectly.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient psychiatric hospital services provided to the enrollee. Our physician reviewer found that treatment was appropriate the day of admission, however the enrollee did not have any thoughts of harming himself as of the day after admission. After August 23, 2019, the enrollee was not shown to be a danger to himself or others and was without agitation or aggression. The enrollee was without perceptual disturbance including auditory or visual hallucinations beginning August 24, 2019 forward.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services provided August 23, 2019 have been met. Therefore, we decided that the Plan must pay for inpatient psychiatric hospital services provided August 23, 2019.
However, we have also decided that the Plan does not have to pay for inpatient psychiatric hospital services provided August 24, 2019 to September 3, 2019, as per medical review, inpatient treatment was no longer necessary.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit for the evaluation and management of an established patient (CPT Code 99334) provided to the enrollee on April 16, 2019.
You asked the Plan to pay for the services. You say that the doctor was not responsible to get authorization. You state the Nursing Home is responsible to obtain prior authorization for their patients, which should cover medical treatments by the provider. The Plan denied your request. The Plan says the member does 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 services are not authorized because a non-network provider who does not work with the member's health plan and the member was referred by his non-participating nursing home. The member's primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. There is no network deficiency for these services and alternate network providers were found. Therefore, we decided that the Plan does not have to pay for domiciliary or rest home visit for the evaluation and management of an established patient (CPT Code 99334) provided to the enrollee on April 16, 2019.
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 you would like the opportunity to have the therapy being requested, as it has worked so well in the past. You say that you cannot work and are not walking. You say that the UTI you had made you very weak and the rehabilitation being requested will benefit you.The Plan denied your request. The Plan says the records do not show that the enrollee needs treatment from a doctor at least three times a week. The Plan says that the enrollee does not need special therapy skills or devices. The Plan says that the enrollee does not need rehab nursing 24 hours a day.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 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 enrollee's medical status does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from physical therapy and occupational therapy, but the documentation does not indicate that he requires this or can tolerate this therapy on an intensive 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-approveacute inpatient rehabilitation facility (IRF) admission and services.