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

We decided that the Plan does not have to pay for services provided on May 11, 2019.
You asked the Plan to pay for the ambulance services. You say that the ambulance service was medically necessary. The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance services. Our physician reviewer found the call for emergency services was described as a seizure, which had occurred nearly two hours prior to the call. Upon arrival of emergency staff, vitals were normal, there was no signs or symptoms suggestive of a post-ictal state which is typical of a true seizure, and the enrollee was able to walk to the ambulance without issues. There was no treatment or medical services needed on arrival or during the transportation to justify ambulance services. Therefore, the enrollee does not meet the requirement for ground ambulance services. 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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for services provided on May 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 24, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available 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 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that the orthotics are a medical necessity for you since you have limited mobility and significant pain without them. You say that your quality of life and standard of health will be diminished without the orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower coinsurance for 1mg Envarsus XR Tablets.
You asked the Plan to pre-approve the lower coinsurance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Part B drugs are not eligible for a cost sharing tier exception.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for each Medicare-covered Part B drug obtained in-network and a 40% coinsurance for each Medicare-covered Part B drug obtained out-of-network. The Envarsus falls within the Medicare Part B Prescription Drugs benefit category. Part B drugs are not eligible for a cost sharing tier exception. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to pre-approve a lower coinsurance for 1mg Envarsus XR Tablets.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 20, 2018 and September 21, 2018.
You asked the Plan to pay for the physician services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 the physician services was not filed until September 27, 2019. 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 the physician services provided on September 20, 2018 and September 21, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avastin eye injections to be provided while out of area (OOA).
You asked the Plan to pre-approve the OOA Avastin injections. You say that you need to get these injections to prevent a loss of vision. The Plan denied your request. The Plan says only urgently needed OOA services are covered by the plan. As the need for these injections is not unforeseen, they are not considered urgently needed.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, and renal dialysis. Urgently needed OOA care is considered services needed due to an unforeseen flare up in a known condition. Scheduled injections, though necessary, do not meet the criterion for urgently needed as the need for them is known prior to leaving the service area. Therefore, we decided that the Plan does not have to pre-approve Avastin eye injections to be provided while out of area (OOA).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities, therapeutic exercises, and the gait training therapy provided from August 15, 2019 to August 28, 2019 by the out of network provider.
You asked the Plan to pay for the skilled nursing facility care. You say that you were not ready for home care or outpatient therapy. The Plan denied your request. The Plan says authorization was not obtained before you received the services.
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 provider in this case is not a network provider with the Plan. 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 therapeutic activities, therapeutic exercises, and the gait training therapy provided from August 15, 2019 to August 28, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the observation services provided from August 5, 2019 to August 12, 2019.
You asked the Plan to reduce the copayment for the observation services. You say that any other time you have gone to the emergency room; you have never received a bill for observation. 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 $250 copayment for observation services. You have been asked to pay a $250 copayment for the observation services. The observation services fall within the "Outpatient hospital services" benefit category. The record shows you received observation services.
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 reduce the copayment for the observation services provided from August 5, 2019 to August 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto for the enrollee.
You asked the Plan to pre-approve Xarelto. The Plan denied your request. The Plan says oral medications are not covered.
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 Xarelto for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional injection for the enrollee.
You asked the Plan to pre-approve the additional injection. The Plan denied your request. The Plan says a post-injection evaluation needs to be documented to show whether the approved injection was successful.
The Plan follows Medicare rules. Medicare rules say that lumbar epidural steroid injections are only covered under certain medical indications.
The file shows that 2 lumbar injections were requested for the enrollee. The plan has agreed to approve 1 injection. 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 additional injection. Our physician reviewer found that the enrollee has low back pain and left sided radiculopathy. A response to each ESI should be determined prior to determining the value of a repeat ESI, and the specific methods used for subsequent ESIs. The medical records do not support that this has been satisfied. Therefore, the requested injection is not medically reasonable at this time. 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 additional injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional injection for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood transfusion, and platelets provided on June 10, 2019 by the out of network provider.
You asked the Plan to pay for the surgical services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not provided in an urgent or emergent situation.
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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. 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 blood transfusion, and platelets provided on June 10, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a intermittent limb compression device (CPT E0652).
You asked the Plan to pre-approve intermittent limb compression device. You say that you have complied with the plan's request. The Plan denied your request. The Plan says the enrollee has not had a four week trial of an E0650 or E0651 non-segmental compression pump. The plan says that the enrollee's request does not meet the conditions for approval.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 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 intermittent limb compression device. Our reviewer says that the requested device is not medically necessary. Our physician reviewer found the records indicate that the enrollee has non-pitting edema and uses compression stockings. Our physician reviewer found that the records do not indicate there is clear hyperkeratosis and/or proximal lymphedema. Our physician reviewer found that the records do not indicate there is a failure to first line methods such as manual lymph drainage (MLD). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve a intermittent limb compression device (CPT E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a home blood glucose monitor (E0607), blood glucose test or reagent strips (A4253), lancets (A4259), calibrator solution/chips (A4256), and spring-powered device for lancet (A4258) provided from May 21, 2019 to August 9, 2019.
You asked the Plan to pay for the home blood glucose monitor, blood glucose test or reagent strips, lancets, calibrator solution / chips, and spring-powered device for lancet. You say that the items were provided and payment should be rendered. The Plan denied your request. The Plan says the documentation provided did not include a valid proof of delivery. Therefore, coverage criteria has not been met.
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 proof of delivery for the supplies provided in this case. Specifically, the delivery ticket is missing a valid signature. Therefore, we decided that the Plan does not have to pay for a home blood glucose monitor (E0607), blood glucose test or reagent strips (A4253), lancets (A4259), calibrator solution / chips (A4256), and spring-powered device for lancet (A4258) provided from May 21, 2019 to August 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management, more than 30 minutes provided on February 11, 2019.
You asked the Plan to pay for hospital discharge day management. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the services billed.
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, the discharge summary does not support that hospital discharge day management of more than 30 minutes was performed. A documented duration of time of 31 minutes or more is required to support this code. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management, more than 30 minutes provided on February 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the treatment you need can be provided in a lower level of 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 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-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient hospital care for the enrollee.
You asked the Plan to pre-approve the requested services. You say that an inpatient hospital level of care is necessary due to the enrollee's comorbidities and current medical needs. The Plan denied your request. The Plan says there is no information as to the need for continued hospitalization.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. 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 services. Our physician reviewer found that the documentation stated that at the time of this request, the enrollee was awaiting rehabilitation placement. Vitals and examination findings were stable, cardiology had signed off, Lasix was being held, encephalopathy had resolved, and only minor medication adjustments were being made. He was stable for discharge to a lower level of care by January 4, 2020, according to the provided records. The provided records do not show that the enrollee would need acute medical services for an additional stay. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient hospital care for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve general anesthesia for your dental procedure.
You asked the Plan to pre-approve general anesthesia. You say that you are experiencing pain and tenderness with your gums. The Plan denied your request. The Plan says the requested services are not covered by Medicare or your plan.
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. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve general anesthesia for your dental procedure.
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 May 29, 2019 to August 17, 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 May 29, 2019 to August 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on September 19, 2019.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the hearing aids. We found no exception that would require the Plan to pay for these services. 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 provided on September 19, 2019.