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

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on September 16, 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 to the enrollee on September 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided from November 13, 2018 to November 19, 2018.You asked the Plan to waive the copayment forthe inpatient hospital stay. You say that you never requested a private room and you were never told there would be a charge for a private room. You say you have already been charged $345 each day for days 1-5 and you are on a very meager fixed income and already have a lot of medical bills. 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 $345 copayment for each day for days 1 to 5 for Medicare-covered hospital care and a $0 copayment for additional Medicare-covered days. You have been asked to pay a total of $1,486.01, which is less than the standard amount, for the inpatient hospital stay. The standard amount is $1,725. ($345 x 5 = $1,725). The inpatient hospital stay falls within the "Inpatient Hospital Care benefit category. The record shows you met your maximum out-of-pocket for this date of service. This means that you have been asked to pay the correctamount 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 inpatient hospital stay from November 13, 2018 to November 19, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 19, 2019 by out of network provider.
You asked the Plan to pay for the non-emergent ambulance transport. You say that the transport was medically necessary. The Plan denied your request. The Plan says you did not request 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. This was a scheduled transport. 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 ambulance services provided on August 19, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair upgraded electronics.
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the enrollee needs the electronic upgrades. The Plan denied your request. The Plan says the enrollee has the strength to control the power options by their switches.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Documentation shows that the enrollee has normal range of motion and 4- to 5/5 strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. Based on this information, we decided that Medicare rules for coverage of the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) have not been met. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair upgraded electronics.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for the difference in cost between the A-C IOL and a conventional IOL. We decided that the Plan does not have to pay for the full cost of the A-C IOL ($1,080).
You asked the Plan to pay for the difference in cost between the A-C IOL and a conventional IOL. You say that you paid a copayment and are now being billed for the A-C IOL. The Plan says that this service is not payable by the Plan.
The Plan follows Medicare rules. The rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. The astigmatism-correcting feature of an IOL is not covered by Medicare. The record does not show that you received payment for the difference between the A-C IOL and a conventional IOL, which is required by Medicare rules. The full cost of the A-C IOL is not a covered benefit of Medicare or the Health Plan. Therefore, we decided that the Plan has to pay for the difference in cost between the A-C IOL and a conventional IOL. We also decided that the Plan does not have to pay for the full cost of the A-C IOL ($1,080).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat or bath tub wall rail.
You asked the Plan to pre-approve a raised toilet seat or bath tub wall rail. You say that you need these items. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats and grab bars are not covered because they are not primarily medical in nature. While a raised toilet seat or grab bar may be appropriate for the enrollee, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat or bath tub wall rail.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on October 2, 2019.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says that he Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 a hospital outpatient clinic visit provided on October 2, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve the Zephyr Valve placement to be performed at an inpatient level of care.
You asked the Plan to pre-approve the inpatient level of care. You say that the Zephyr Valve procedure is performed as an inpatient procedure. You say that the FDA approved labeling for the product includes a recommendation for a 3 night stay minimum after the procedure to appropriately manage pneumothorax risk. The Plan denied your request. The Plan says that the procedure can be performed in an outpatient setting.
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 inpatient level of care. Our reviewer says that the requested inpatient level of care is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD). The enrollee has been approved for placement of a Zephyr valve. The FDA labeling for the Zephyr valve states that, due to a high risk for pneumothoroax, the enrollee should remain in the hospital for 3 days after placement. The inpatient level of care is medically reasonable and necessary for the enrollee in this case. 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 inpatient level of care have been met. Therefore, we decided that the Plan has to pre-approve the Zephyr Valve placement to be performed at an inpatient level of care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on August 26, 2019.You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a drug test provided on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Part B drug, the drug administration, and the specialist's office visit provided on July 16, 2019 and August 2, 2019You asked the Plan to waive the cost share forthe Part B drug, its administration, and the specialist office visit. You say that you were never informed about the cost share. You say this is hard for you to pay because you are on a limited income.The Plan denied your request. The Plan says you havebeen 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 youmust pay 20% coinsurance for each in-network Medicare-covered Part B drug a $35 copayment for services obtained from an in-network specialist. You have been asked to pay a total of $1,760.83 for the Part B drug, its administration, and the specialist office visit. The Part B drug falls within the "Medicare Part B Prescription Drugs" benefit category. The drug administration and the specialist office visit fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" 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 cost share forthe Part B drug, the drug administration, and the specialist's office visit provided on July 16, 2019 and August 2, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 19, 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 August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cord manipulation procedure provided on July 19, 2019.
You asked the Plan to waive the copayment for the cord manipulation procedure. You say that nobody discussed the cost for the procedure with you. You say that you are challenging the bill. The Plan denied your request. The Plan says 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 $35 copayment for services obtained from a specialist. Covered services include medically-necessary medical or surgical services furnished in a physician's office. You have been asked to pay a $35 copayment for the cord manipulation procedure. The cord manipulation procedure falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" 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 cord manipulation procedure provided on July 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision for and insertion of a chest wall respiratory sensor electrode (0466T and 64568). You asked the Plan to pay for hypoglossal stimulation. You say that you would like reconsideration as you meetcriteria for this service. The Plan denied your request. The Plan says this service has not been established as an effective option and remains unproven.The Plan must follow Medicare rules. Medicare rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR 411.15 and 411.15(o).We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hypoglossal stimulation have not been met. Specifically, per Local Coverage Determination (LCD): Non-Covered Services (L36219), 0466T for hypoglossal stimulation is a non-covered service. Therefore, we decided that the Plan does not have to pay for the incision for and insertion of a chest wall respiratory sensor electrode (0466T and 64568)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on October 10, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says criteria for the orthosis was not met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the lumbar-sacral orthosis (L0650). Our physician reviewer found the enrollee's chief complaint was back pain. The available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe resin based composite, 2 surfaces, anterior (D2331,) for tooth # 25, and the resin based composite, 1 surface, posterior (D2391) for tooth # 29 provided on June 19, 2019.You asked the Plan to reimburse you forthe dental services. You say that the services were denied because you had 2 fillings on the same teeth within 24 months. You say that you did not know about that "rule".The Plan denied your request. The Plan says the frequency limit has been exceeded.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 and fillings are a covered surface, they are limited to 1 per tooth, per surface, every 2 years.Therefore, we decided that the Plan does not have to reimburse you forthe resin based composite, 2 surfaces, anterior (D2331,) for tooth # 25, and the resin based composite, 1 surface, posterior (D2391) for tooth # 29 provided on June 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that due to the enrollee's complex medical needs and failed treatment at a lower level, the best course of action is to admit her to the LTACH.The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no required medical services identified that are available at the LTACH but not available at the current health care setting being offered by the Plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided from August 20, 2019 to August 27, 2019.
You asked the Plan to pay for skilled nursing services. You say that these services are not pre-scheduled and therefore an authorization was not obtained for these services. 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 skilled nursing services provided from August 20, 2019 to August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on September 9, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee on September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device and appliances from the provider.
You asked the Plan to provide a pneumatic compression device (E0652) and appliances.. You say that the enrollee needs the Flexitouch pneumatic compression device. The Plan denied your request. The Plan says the enrollee has not had a four week trial with a basic device.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 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, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to provide a pneumatic compression device and appliances from the provider.