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

We decided that the Plan does not have to pay for an intermittent limb compression device provided to the enrollee October 29, 2019.You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device provided to the enrollee October 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humalog for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee is allergic to Novolog. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Humalog for the enrollee.
Benefits for this drug 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits.You asked the Plan to pre-approve home health care. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the enrollee does not meet the Medicare criteria for home health skilled nursing care.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home health care. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested home health care visits. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee. The enrollee has chronic medical conditions which he has been educated in and does not require the ongoing professional skills of a nurse at home. There is no complex wound care, intravenous antibiotic, or other ongoing skilled nursing needs, therefore the request for additional home health skilled nursing visits is not 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 home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on December 9, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you are entitled to a free colonoscopy every ten years. You say the colonoscopy should be considered preventive because it was ensuring that internal bleeding does not worsen. 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 an ambulatory surgical center. You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows the colonoscopy was performed due to iron deficiency anemia. Therefore, the colonoscopy is diagnostic in nature.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 forthe colonoscopy provided on December 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill (99291) provided on August 5, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the billed services were not supported in the record.
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 99291 is critical care, evaluation and management of the critically ill, first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, CPT code 99291 is a time based code. In order to bill CPT code 99291, the documentation must note that 30-74 minutes was spent providing services to the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill (99291) provided on August 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for edge polishing (V2799) anti-reflective coating (V2750) polycarbonate lens (V2784) U-V lens (V2755) purchased January 30, 2020.You asked the Plan to pay for the vision services. You say that you had a previous head injury and cataracts and you were advised to wear sunglasses and  feel it is important for safety to have these lenses.The Plan denied your request. The Plan says these services are covered under the plan benefits.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when only single vision, lined bifocal and lined trifocal lenses are covered every 24 months. Lens enhancements are not covered.We looked at the file and the Plan's rules. these services are covered under the plan benefits. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay foredge polishing (V2799) anti-reflective coating (V2750) polycarbonate lens (V2784) U-V lens (V2755) purchased January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 2, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee 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 to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services, an injection and an x-ray provided on January 15, 2020 by an out of network (OON) provider.You asked the Plan to pay for physician services, an injection and an x-ray. 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 for 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 physician services, an injection and an x-ray provided on January 15, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 26, 2019 by an out of network (OON) provider. You asked the Plan to pay for the OON services. You say that you did not know authorization was needed. The Plan denied your request. The Plan says the services received were not authorized. 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 file shows that you received a hospital outpatient clinic visit and iridotomy procedure. 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. There are insufficient medical records to show that the services were urgent. 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 medical services provided on December 26, 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 vision care received on November 13, 2019.
You asked the Plan to pay for the services. You say that you are entitled to a $100 reimbursement for these services. The Plan denied your request. The Plan says the claim was processed appropriately.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these non-Medicare covered eyewear at an $100 allowance per year. We looked at the file and the Plan's rules. There is a $100 allowance for the services received at issue in this case. However, it appears that the $100 allowance was already exhausted with eyewear purchased on June 6, 2019. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for vision care received on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 28, 2019 by an out of network (OON) provider.You asked the Plan to pay for the flow cytometry (88187). You say that you would like reconsideration because you are not required to obtain authorization.The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan 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 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 November 28, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a sitting computed tomography (CT) scan.
You asked the Plan to pre-approve the sitting CT scan. You say that it would be physical impossible for you to have the type of CT scan being offered in-network. You say that the out of network doctor offers a type of CT scan that allows her to sit in a chair. The Plan denied your request. The Plan says that the notes provided show that a CT scan can be done with the in-network providers and there is not a medical need for the enrollee to receive care out-of-network.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 sitting CT scan. Our reviewer says that it is medically necessary for the enrollee to receive a sitting CT scan. Our physician reviewer found the documentation shows the enrollee is unable to position herself for a dobutamine echocardiogram. The plan is not offering adequate care to meet the enrollee's medical needs through their referral to a provider who can perform a CT scan in which the enrollee lays down. The enrollee's condition is unique in that it makes a sitting CT scan medically necessary, and the plan has not shown that they this necessary care can be supplied through one of their in-network providers. 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 sitting CT scan have been met. Therefore, we decided that the Plan has to pre-approve a sitting computed tomography (CT) scan.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay this claim as originally billed. You asked the Plan to pay for these services. You say that this claim should be paid by the Plan.The Plan says a corrected claim is needed in order to make payment. The Plan agrees the claim should be paid;however,the claim was not billed with the correct value code to indicate the CBSA for general inpatient care.The Plan states a corrected claim is needed from the provider.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. Medicare rules say that hospice providers must report the appropriate CBSA location code. In this case, the claim submitted cannot be paid as billed. The Plan agrees that this service is covered but cannot process the claim submitted. The Plan states a corrected claim is needed for payment.  Therefore,we decided that the Plan does not have to pay for services provided to the enrollee from May 10, 2019 to May 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 5, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 medical services provided to the enrollee by an out-of-network provider on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650), a wrist-hand orthosis (L3916), and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on August 19, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
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/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650), a wrist-hand orthosis (L3916), and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on January 23, 2020.
You asked the Plan to pay for the vaccine. You say that you were told this would be covered. The Plan denied your request. The Plan says this is not covered under Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on January 23, 2020.
Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 9, 2019 by a non-plan provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-plan 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 laboratory services provided on December 9, 2019 by a non-plan provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the records show that medical conditions have improved, and you do not need to be seen by a rehab doctor three times a week.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable period. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 medical services provided to the enrollee by an out-of-network provider on January 6, 2020.