Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) and lumbar-sacral orthosis (L0650)
provided to the enrollee on October 31, 2019.
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says the services are not supported by the records.
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 orthoses have not been met.
Healthcare Common Procedure Coding System (HCPCS) code L0650 (1 Unit) remains not supported. The
submitted DME order do not specify that the lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid
anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral
strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on
intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen
design, prefabricated, off-the-shelf was ordered; therefore, the billed service cannot be verified. It is noted that
multiple attempts were made to contact the provider for additional information.
Healthcare Common Procedure Coding System (HCPCS) code L1833 LT KX (1 Unit) remains not supported.
The submitted DME order do not specify that the knee orthosis (KO), adjustable knee joints (unicentric or
polycentric), positional orthosis, rigid support, prefabricated, off-the shelf was ordered; therefore, the billed
service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional
information. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) and lumbarsacral
orthosis (L0650) provided to the enrollee on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a rheumatology consultation.
You asked the Plan to pre-approve the rheumatology consultation. You say that you would like reconsideration
because you are in pain and unable to perform normal daily functions. The Plan denied your request. The Plan
says this consultation is 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 the rheumatology consultation. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found The primary provider has not provided a differential diagnosis or rationale
for the requested consult.
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 rheumatology consultation have not been met. Therefore, we decided that
the Plan does not have to pre-approve a rheumatology consultation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 6, 2020 by an out of network (OON) provider.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 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 forthe physician services provided on January 6, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skyrizi Injections.You asked the Plan to pre-approve Skyrizi Injections. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Skyrizi Injections are not covered under the enrollee's Medicare Part B benefit.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 Skyrizi Injections.Benefits for Skyrizi Injections 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT image capture with limited field of view (D0380) and consultation (D9310) provided on March 25, 2020.
You asked the Plan to pay for the cone beam CT image capture and consultation. You say that these services were a medical emergency due to an abscess and an emergency root canal. You also say that if you had not been seen for these services, you would not have recovered, and could have led to a disability. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam CT image capture with limited field of view (D0380) and consultation (D9310) provided on March 25, 2020.
Your complaint about your dissatisfaction with the Plan's coverage 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee on February 7, 2020.You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the services are not supported by the records.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 orthoses have not been met. The documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee on February 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962).
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that they have determined that this service is not covered under Medicare.
The Plan must follow Medicare rules. Medicare rules say that the protective outer surface covering system is used by a beneficiary who has special needs for protection against unusually harsh environmental situations. We looked at the file and Medicare rules. The record does not show you are subject to a harsh environmental situation. 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 an addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962).
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 you were attending a church service when you began to feel light-headed and you fell into the pew. You say that several people came to help you, and someone called for an ambulance. You stated that when the ambulance arrived, the paramedics checked your vitals and told you that they were okay. You say that you did not go to the hospital and the paramedics told you that you should follow up with your doctor. You asked the Plan to reconsider providing coverage because you were not aware that you needed to go to the hospital for the ambulance services to be covered. 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 January 5, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for specialist services, injection and x-ray services provided on March 25, 2020.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost share was charged based on the services provided and the Plan contract agreement.
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 cost share for Part B injection, x-rays, and specialist services. 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 cost share charged for specialist services, injection and x-rays provided on March 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of the heart.
You asked the Plan to pre-approve the CT of the heart. You say that the requested service is needed for cardiac
clearance. The Plan denied your request. The Plan says the request is not indicated at this time.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically 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 the CT of the heart. Our reviewer says
that the requested CT scan is not medically necessary. Our physician reviewer found the enrollee has increased
coronary risk. In this setting, screening cardiac CT scanning with calcium scoring is not recommended and has
not been shown to improve cardiac outcome incremental to that achievable based on treatment guided by
standard clinical risk profiling and basic lipid analysis alone.
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 CT of the heart have not been met. Therefore, we decided that the Plan does
not have to pre-approve computed tomography (CT) of the heart.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on July 5, 2019 by an out of network
(OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that
the member's primary care physician did not refer 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 lab work provided on July 5, 2019 by an out of
network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the colorectal screening (81528) provided on January 13, 2020.You asked the Plan to pay for the colorectal screening. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the enrollee had already reached their benefit limit for this service.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan is denying payment for the colorectal screening (81528) provided on January 13, 2020 due to the benefit limit having already been reached. The Plan says that the enrollee received a prior colorectal screening less than 3 years ago in 2017. However, the Plan has not provided any documentation showing that the benefit had already been reached or paid for. We find that the Plan has not substantiated their reasoning for denial.Therefore, we decided that the Plan has to pay for the colorectal screening (81528) provided on January 13, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora cancellation policy for a flight on January 6, 2019 and a plane ticket for July 31, 2019.You asked the Plan to pay fora cancellation policy and a plane ticket. You say that these costs should be covered.The Plan denied your request. The Plan says these costs are not included in the transplant benefit.The Plan must follow Medicare rules. Medicare rules say that in any circumstance in which an MA plan provides transplant services at a more distant location, the MA plan must Provide reasonable transportation for the enrollee and a companion to the distant facility. The provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.We looked at the file and Medicare rules. Cancellation policies are not considered part of reasonable transportation. While flights are included in this benefit, the receipts submitted do not show a flight for July 31, 2019 was purchased. Based on this information, we decided that Medicare rules for coverage of a cancellation policy and a plane ticket have not been met.Therefore, we decided that the Plan does not have to pay fora cancellation policy for a flight on January 6, 2019 and a plane ticket for July 31, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to waive the coinsurance for a Skilled Nursing Facility (SNF) stay provided from March 1, 2020 to March 25, 2020. You asked the Plan to waive the coinsurance for SNF stay. You say that you were told by the facility that they would appeal the last 5 days of the SNF stay so the enrollee would not be charged a coinsurance. The Plan denied your request. The Plan says that the coinsurance amount the enrollee is being charged is correct.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 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 says that enrollees must pay 50% coinsurance for days 21 to 100 of an in-network SNF stay. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan says that the enrollee must pay $778.36 coinsurance amount for this stay. The Plan did not provide a clear itemization of the allowed amounts of each day of this SNF stay to justify the coinsurance amounts being charged for days 21 to 24 of the stay. We requested this information, however it was not provided to us because the Plan's response to our request merely reiterated the coinsurance amount the enrollee was asked to pay as opposed to the allowed amount of each day which was used to calculate this coinsurance. Furthermore, the Plan says that the coinsurance amount applied met the enrollee's maximum out-of-pocket amount for 2020, however the Plan did not provide the applicable section of the Evidence of Coverage (EOC) which describes the maximum out-of-pocket amount for 2020. Without this information, we cannot determine if the coinsurance amount the enrollee is being asked to pay is correct, nor if this amount exceeds the maximum out-of-pocket amount for 2020 according to the enrollee's benefits. Therefore, the Plan has not shown that the coinsurance amount the enrollee is being charged is correct or justified according to Medicare rules or the Plan contract. Therefore, we decided that the Plan has to waive the coinsurance for a Skilled Nursing Facility (SNF) stay provided from March 1, 2020 to March 25, 2020.
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.The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient rehabilitation facility admission.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 that the complexity of your nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an inpatient rehabilitation facility. You may benefit from multiple therapies such as physical and occupational therapy, but the documentation provided does not support that your functional status requires 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 10, 2020 by an out of network (OON) provider.You asked the Plan to pay for these services. You say that you were under the impression the doctor was part of the plan.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 medical services provided on January 10, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on February 27, 2020.You asked the Plan to pay for the services. You say that the lab performed all of the tests that were ordered by the referring physician.The Plan denied your request. The Plan says Medicare says non-urgent services should be from network providers who are contracted with the health plan and listed in the Provider Directory.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 lab services provided to the enrollee on February 27, 2020.