Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ECG provided on July 5, 2019.You asked the Plan to pay for the ECG. You say that the services were provided in a nursing home and there is no option for the enrollee to find a participating provider. The Plan denied your request. The Plan says services provided by an out-of-network provider require 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 caseand the referring provider are not network providers with the Plan. The Plan did not pre-approve the servicesat 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 an ECG provided on July 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided on June 4, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided on June 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that since you were not transported to the
hospital there should be no balance due. 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 16, 2019. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from August 19, 2019 to November 7, 2019.You asked the Plan topay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from August 19, 2019 to November 7, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from August 13, 2019 to October 1, 2019.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you should not be responsible for the copayments. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for outpatient rehabilitation services. You have been asked to pay a $20 copayment for each of the physical therapy visits. The physical therapy visits fall within the "Outpatient rehabilitation services" 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 copayments for the physical therapy visits provided by from August 13, 2019 to October 1, 2019.
Your complaint that the physical therapy exercises were unnecessary and exasperated your issue the 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forradiation treatments provided on February 27, 2018 and February 28, 2018.You asked the Plan to waive the copayment forradiation treatments. You say that the machine was defective. You say that your cost should be less.The Plan denied your request. The Plan says the copayments 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 a $50 copayment per visit for therapeutic radiological procedures. You have been asked to pay a $50 copayment for each radiation treatment. The total amount you owe is $100 ($50/treatment x 2 treatments = $100). Radiation treatments fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that radiation treatments were provided. 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 forradiation treatments provided on February 27, 2018 and February 28, 2018
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 12, 2019 to October 31, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is no valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 12, 2019 to October 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continued skilled nursing facility (SNF) services July 30, 2019 to August 20, 2019.You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services.The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does 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 the SNF services have not been met.Therefore, we decided that the Plan does not have to pay forcontinued skilled nursing facility (SNF) services July 30, 2019 to August 20, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 3, 2019.
You asked the Plan to pay for the imaging services. You say that the plan should pay the claim since the services were not related to the hospice diagnosis and hospice services were revoked. The Plan denied your request. The Plan says under Medicare guidelines Original or Traditional Medicare is still responsible for payment until the start of the next month after revocation.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 03, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on July 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower partial denture (D5214) provided on September 24, 2019.
You asked the Plan to pay for the lower partial denture (D5214). You say that you were told the dentures were covered. You say you need the dentures. The Plan denied your request. The Plan says this is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the lower partial denture (D5214) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the lower partial denture (D5214) provided on September 24, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the extraction for tooth #11. We decided that the Plan does not have to
pay for the customization of the dentures provided on September 19, 2019.
You asked the Plan to pay for the extraction for tooth #11. The Plan says that the annual maximum of $1,000
has been reached. The Plan also says that the customization of dentures is not listed as a covered service.
We decided that the Plan has to pay for the extraction for tooth #11. The record shows that the annual
maximum of $1,000 has not been reached.
Therefore, we decided that the Plan has to pay for the extraction for tooth # 11.
We also decided that the Plan does not have to pay for the customization of the dentures. The
customization of dentures is not listed as a covered service. Therefore, we decided that the Plan does not have
to pay for the customization of the dentures provided on September 19, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the current procedural terminology (CPT) codes 81120, 81121, 81173, 81201, 81210, 81235, 81272, 81275, 81310, 81311, 81314, 81321, 81270, 81276, 81293, 81301, 81400, 81401, 81402, 81403, and 81404 provided on September 3, 2019.
You asked the Plan to pay for the CPT codes 81270, 81276, 81293, 81301, 81400, 81401, 81402, 81403, and 81404. You say that the facility is the only service provider for testing. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. It is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the current procedural terminology (CPT) codes 81120, 81121, 81173, 81201, 81210, 81235, 81272, 81275, 81310, 81311, 81314, 81321, 81270, 81276, 81293, 81301, 81400, 81401, 81402, 81403, and 81404 provided on September 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that the enrollee is not ambulatory at all and deserves to have the bill paid. You say that the Plan has paid other claims for the same services provided.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 forthe ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on June 7, 2019 by an out of network provider.
You asked the Plan to pay for podiatry services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The
Plan says that there are multiple in-network providers available within 30 miles of the member's residence that
could have provided these 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 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 podiatry services provided on June 7, 2019 by the out of network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage, and the ambulance service, advanced
life support, emergency transport provided on September 1, 2019.
You asked the Plan to pay for the transportation services. You say that the service was a 911 call. You also say
that you feel the enrollee was treated based on the call. The Plan denied your request. The Plan says the
enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits
starting on the date of election until the last day of the month in which hospice is revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the ground mileage, and the ambulance service, advanced life
support, emergency transport provided on September 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx testing rendered on January 27, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing was not medically necessary.The Plan must follow Medicare rules. Medicare rules say that targeted genomic sequence analysis is covered when specific criteria are met.We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the testing was not medically necessary. Our physician reviewer found the enrollee has a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung. He had Stage IIIB poorly differentiated non-small cell lungcancer (NSCLC). The FoundationOne CDx testing in this case consisted of analysis of 324 genes. In addition, the documentation does not indicate how this testing was to be used to guide decision making in regard to treatment. The testing was therefore 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 pay forthe FoundationOne CDx testing rendered on January 27, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by the out of network provider.
You asked the Plan to pre-approve endoscopy and colonoscopy. You say that the provider the enrollee is being required to see has extremely low quality of care. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.
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 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. 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 medical services to be provided by the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis Tab 5mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this medication does not fall under Part B coverage.
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 Eliquis Tab 5mg for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex spacer for the enrollee.
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 services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has back pain. The requested Vertfilex spacer is considered experimental/investigational in nature. More research is needed. The services are therefore not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex spacer for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) for the enrollee.
You asked the Plan to pre-approve these services. You say that physical therapy has not given the enrollee any pain relief. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that SCS implantation is covered when specific criteria are met. 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 a history of back pain. The criteria for coverage of SCS implantation are not met, as he has not tried and failed a course of recent physical therapy. The services are therefore 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 a spinal cord stimulator (SCS) for the enrollee.