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

We decided that the Plan does not have to pay for the outpatient clinic services provided on October 7, 2019 by an out of network (OON) provider.You asked the Plan to pay for the outpatient clinic services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the outpatient clinic services provided on October 7, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on November 4, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a podiatry office visit provided on February 25, 2019.You asked the Plan to waive the copayment for podiatry visit. You say that a copayment should not have been applied to this visit.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $40 copayment for each non-routine covered podiatry visit. The record shows that this visit was provided to address a non-routine issue, therefore the non-routine podiatry copayment applies to this visit.You have been asked to pay $40 copayment for podiatry visit. Podiatry visit falls within the Podiatry Services -Medicare-covered 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 copayment fora podiatry office visit provided on February 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe massage therapy services provided from September 12, 2019 to October 6, 2019.You asked the Plan to pay forthe massage therapy 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 by Medicare or the Plan.The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist.Therefore, we decided that the Plan does not have to pay forthe massage therapy services provided from September 12, 2019 to October 6, 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 you declined transportation by ambulance after the emergency responders had completed your examination. You say that you want to appeal the Plan's denial and you believe the services should 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 14, 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: DME/ Orthotics
Decision: Unfavorable

We decided that thePlan does not have to pre-approvean automatic blood pressure monitor.You asked the Plan to pre-approvean automatic blood pressure monitor. You say that the requested item is necessary.The Plan denied your request. The Plan says the item is not primarily medical in nature. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvean automatic blood pressure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the contrast material injection rendered on September 10, 2019. 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 code A9579 is 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. In this case, the CPT Code Manual definition of code A9579 is injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml. We find that CPT code A9579 is not supported in the medical record. Specifically, there is no documentation of 10 units of a gadolinium-based magnetic resonance contrast agent injection. 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 contrast material injection rendered on September 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEliquis.You asked the Plan to pre-approvethis drug. You say that this is needed to prevent strokes.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-approveEliquis.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0673, E0651).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 fora pneumatic compression device (E0673, E0651).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits (92014), lens polycarb or equal Lens, polycarbonate or equal, any index, per lens (V2784) and anti-reflective coating, per lens (V2750) provided on January 22, 2020.You asked the Plan to pay for the vision services. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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. Review of the file show that you received vision services and eyewear provided on January 22, 2020. The Plan paid the $500 from your allowance and you were asked to pay the reminder of $334. However, the Plan states they contacted the provider who billed CPT Code 92014 in error. The billed code should have been CPT 92015 for refraction which is bundled with the examination. The charge of $46 has been removed for this service and your new responsibility is $288. This is because you exhausted your $500 allowance and you are responsible for the remainder of the cost.Therefore, we decided that the Plan does not have to pay for ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits (92014), lens polycarb or equal Lens, polycarbonate or equal, any index, per lens (V2784) and anti-reflective coating, per lens (V2750) provided on January 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse youfor first class airline tickets purchased on July 16, 2019.You asked the Plan to reimburse youfor the first class airline tickets. You say that you had to travel home lying flat and that was not possible in economy.The Plan denied your request. The Plan says covered ambulance services are to the nearest appropriate facility.The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. We looked at the file and Medicare rules. You were not transported by air ambulance and not transported to the closest appropriate facility. Based on this information, we decided that Medicare rules for coverage of for the first class airline tickets have not been met.Therefore, we decided that the Plan does not have to reimburse youfor first class airline tickets purchased on July 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on December 26, 2019 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 for the physician services provided on December 26, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on August 19, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order, proof of Delivery or a 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 physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order or proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on August 19, 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 you had fallen and your husband could not help you up. You say that the paramedics came and assisted in getting you up. The paramedics then checked your vitals to make sure that you were okay and asked if you would like to go to the hospital. You say that you declined because you were in Pennsylvania and were heading backto New York. You stated that you did not feel it was necessary to go to the hospital at that time. You say that you do not feel that the claim should be denied.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 November 26, 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 forthe ambulance services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health nursing services provided to the enrollee.
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 Medicare billing criteria were not met. The Plan says that the claim submitted has an incorrect bill type. The Plan states a corrected claim is required.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim submitted has an incorrect bill type. Medicare billing criteria are not met. The Plan states a corrected claim is required. Therefore, we decided that the Plan does not have to this claim as originally billed.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Fluorodeoxyglucose f-18 fdg (A9552) provided on May 29, 2019.
You asked the Plan to pay for the Fluorodeoxyglucose f-18 fdg. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code.
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, we have confirmed that code the Fluorodeoxyglucose f-18 fdg has a bundled relationship with code 78306 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for Fluorodeoxyglucose f-18 fdg (A9552) provided on May 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided from October 25, 2019 through November 21, 2019.You asked the Plan to pay forthe services. You say that you feel this claim denied incorrectly.The Plan denied your request. The Plan says your records show that another insurance provider was your insurer at the beginning of this hospitalization.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 services have not been met. Review of the file shows that you were not enrolled with the plan when you were receiving the services. You were enrolled with the plan on November 1, 2019; however, you were admitted for inpatient care on October 25, 2019. Your records show that another insurance provider was your insurer at the beginning of this hospitalization.Therefore, wedecided that the Plan does not have to pay forthe services provided from October 25, 2019 through November 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 10, 2020.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that the copayment 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 $350 copayment for Medicare-covered ambulance services per trip. You have been asked to pay a $350 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance services per trip 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 copayment for the ambulance transport provided on January 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forbifocal vision prescription lens (safety, athletic, or sunglass), per lens (S0506) and progressive lens, per lens (V2781) provided on January 23, 2020.You asked the Plan to pay forthe eyewear. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.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. We looked at the file and the Plan's rules. Review of the file show that you received bifocal vision prescription lens (safety, athletic, or sunglass), per lens (S0506) and progressive lens, per lens (V2781) provided on January 23, 2020. You exhausted your maximum benefit allowance, because the plan paid the $250 and you are responsible for the remainder of the cost. Your EOC states, there is a $250 allowance for supplemental eyewear every year.Members are responsible for all costs over and above the allowance amount.Therefore, we decided that the Plan does not have to pay forbifocal vision prescription lens (safety, athletic, or sunglass), per lens (S0506) and progressive lens, per lens (V2781) provided on January 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level does not require or indicate that this therapy must be in an IRF with an intensive level program.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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed with a Group 1 pressure-reducing mattress overlay.You asked the Plan to pre-approve the semi-electric bed and Group 1 mattress overlay. You say that you feel that this equipment will be necessary for 30-45days as you heal from the fracture.The Plan denied your request. The Plan says the requested equipment is not shown to be medically necessary based on Medicare rules.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the above criteria are met. Group 1 mattress overlays are covered for enrollees with pressure ulcers who have limited mobility. 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 semi-electric bed and Group 1 mattress overlay. Our reviewer says that the documentation does not support that the requested items are medically reasonable and necessary. Our physician reviewer found the enrollee was struck in the left hip area on 05/16/2020 by a log while using a wood splitter. He had immediate onset of pain in the left hip area and difficulty bearing weight. Imaging showed evidence of a fracture of the left iliac wing but no other fracture. Orthopedics recommended non-operative treatment and weight bearing as tolerated. He is ambulating with crutches. The documentation does not support that the patient's condition requires position of the body in ways not feasible in an ordinary bed. There is no evidence he requires frequent changes in body position or the need for immediate body position changes. There is also no evidence that the criteria for a Group 1 mattress overlay are 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 the semi-electric bed and Group 1 mattress overlay have not been met.Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed with a Group 1 pressure-reducing mattress overlay.