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

We decided that the Plan does not have to pay for medical services provided to the enrollee on April 15, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election on the date of service, this claim should be submitted to Original Medicare.

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 medical services provided to the enrollee on April 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear you received on July 6, 2019.
You asked the Plan to pay for the eyewear. You say that you were told by the provider that you would be
reimbursed $150. The Plan denied your request. The Plan says sale items are not eligible for reimbursement.
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 does not cover sale eyewear or eyewear combined with other store discounts.
We looked at the file and the Plan's rules. The eyewear in question was purchased on sale/discount. The Plan
does not reimburse for items that were purchased on sale/discount. Based on this information, we decided that
the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not
have to pay for the eyewear you received on July 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the services you received from March 9, 2021, to March 30, 2021.
You asked the Plan to adjust the cost share. The Plan denied your request. The Plan says the claim processed 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 20% coinsurance for Medicare-covered Part B prescription drugs. Your contract with the Plan also says that you must pay a $35 copayment for each specialist office visit.
Review of the file shows that you had four specialist visits and were provided Part B drugs from March 9, 2021, to March 30, 2021. You have been asked to pay a 20% coinsurance for the Part B drugs and a $35 copayment for each specialist visit. 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 adjust the cost share for the services you received from March 9, 2021, to March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on January 19, 2021.
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 procedure codes S1015 and S8301 are not supported.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure codes S1015 (IV tubing extension set) and S8301 (infection control supplies). These codes have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the supplies rendered on January 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injection, right knee.
You asked the Plan to pre-approve Euflexxa (J7323). You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says the enrollee has not tried and failed Monovisc and Orthovisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Euflexxa (J7323). Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found the documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Euflexxa is not approved as step criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa (J7323) have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injection, right knee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec ODT.
You asked the Plan to pre-approve Nurtec ODT. The Plan denied your request. The Plan says this is not covered under the enrollee's Part B plan.
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 Nurtec ODT.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 30, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient home visit (99347) provided on September 30, 2019 by an out-of-network (OON) provider.

You asked the Plan to pay for the home visit. You say that you request for review of the medical records and process the claim for payment. The Plan denied your request. The Plan says documentation indicates services are not necessary for treatment of the enrollee's condition.

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 rules also say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. Per CMS (Centers for Medicare & Medicaid Services) rules home visit services (CPT (Current Procedural Terminology) codes 99341-99350) may only be billed when services are provided in the beneficiary's private residence (place of service 12). To bill these codes, the physician must physically be present in the beneficiary's home. The provided records do not support that a physician or non-physician practitioner where physically present. The submitted code does not appropriately reflect the services provided by the registered nurse.

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 established patient home visit (99347) provided on September 30, 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 the osseous surgeries (D4260 and D4261 x3), bone replacement graft (D4263 x2), and guided tissue regeneration (D4266) provided on March 4, 2021.
You asked the Plan to pay for the osseous surgeries, bone replacement graft, and guided tissue regeneration. You say that the schedule of benefits includes coverage for non-Medicare covered comprehensive dental services which includes periodontic services which are the type of services you received. The Plan denied your request. The Plan says these services are not covered.
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 osseous surgeries (D4260 and D4261 x3), bone replacement graft (D4263 x2), and guided tissue regeneration (D4266) provided on March 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for twelve (12) additional routine transportation trips.

You asked the Plan to provide coverage for twelve (12) additional routine transportation trips. The Plan denied your request. The Plan says your benefit only allow for 12 one-way trips per calendar year.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at your request, the records in the case file, and the rules. The file shows that your benefit only allows for twelve (12) one-way trips per calendar year. Therefore, we decided that the Plan does not have to provide coverage for twelve (12) additional routine transportation trips.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for transthoracic echocardiography (93306) provided February 8, 2021.
You asked the Plan to pay for the diagnostic service. You say that you received a bill that the insurance paid and you owed a balance of $191.70. You are continuously receiving bills form providers and hospitals before any information is provided by the insurance company. The Plan denied your request. The Plan says the claim was processed, and the cost share was applied to the deductible correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $1,000 deductible. Until you have paid the deductible amount, you must pay the full cost of your covered services. The item or service you asked the Plan to pay for falls within the benefit category Outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 deductible. This cost sharing is a contractual obligation that had not been met at
the time the diagnostic service was received on February 8, 2021. Therefore, we decided that the Plan does not
have to pay for transthoracic echocardiography (93306) provided February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on February 10, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87486, 87801, and 87150) provided on August 5, 2020.

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 are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (87486, 87801, and 87150) provided on August 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on April 5, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport (A0998). The Plan denied your request. The Plan says the ambulance service provided treatment only and no transportation to the nearest appropriate facility was provided as the member declined a transfer.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. Medicare rules also say that 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. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on April 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 28, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 laboratory services provided on September 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from June 6, 2019, through June 7, 2019.
You asked the Plan to pay for the hospital services. You say that the claim was filed timely. The Plan denied your request. The Plan says the claim was received on April 29, 2021, which is past the allowed 12-month timeframe.
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 hospital services was not filed until April 29, 2021. 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 hospital services provided from June 6, 2019, through June 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307) rendered by the out-of-network (OON) provider on March 30, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug testing (80307) rendered by the out-of-network (OON) provider on March 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee has suffered a left sided cerebrovascular accident (CVA) resulting in impairments of function including weakness (worse on the right side) fatigue, difficulty ambulating, standing, transferring, speech and swallow difficulties. You state this in addition to chronic back pain, painful peripheral neuropathy, joint pain. You state this enrollee is an excellent candidate. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness, acute kidney injury and rhabdomyolysis after a fall. Medical conditions are stable.
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program. The enrollee does require physical and occupational therapy but there is no documented need for an
intensive rehabilitation program. Medically necessary services can be provided in a different level of care.
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the
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 acute IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on October 19, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status on the date of service, this claim should be submitted to Original Medicare.
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 medical services provided to the enrollee on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (G0483) provided on December 18, 2020.
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 are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (G0483) provided on December 18, 2020.