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

We decided that the Plan does not have to pay for physician's services provided on August 7, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.
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 August 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are medically 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 Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs or skilled therapy service needs. The enrollee does not meet severity of illness or intensity of
service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a magnifier provided by on May 31, 2019.You asked the Plan to reimburse you for the magnifier.The Plan denied your request. The Plan says low vision aids are not covered by Medicare.The Plan must follow Medicare rules. The rules say that Medicare does not pay for low vision aids.This exclusion includes all devices that use one or more lenses to aid vision or magnify images.We looked at the file and the Medicare rules. The magnifieryou asked the Plan to reimburse you for is considered a low vision aid.Medicare does not pay for low vision aids.Therefore, we decided that the Plan does not have to reimburse you for a magnifier providedon May 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on August 9, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that you should not have to pay the copayment. 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 $40 copayment for laboratory services at an in-network outpatient hospital. You have been asked to pay a $40 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 laboratory work provided on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nerve conduction studies coded 95913, the needle
electromyography services coded 95886, and the needle electromyography using single fiber electrode services
coded 95872 provided from June 24, 2019 to July 15, 2019.
You asked the Plan to pay for the nerve conduction studies, the needle electromyography services, and the
needle electromyography using single fiber electrode services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.
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 CPT codes 95913, 95886, and 95872 are not supported in the medical record. Specifically, the
documentation submitted does not include that nerve conduction studies, 13 or more studies were performed.
Therefore, code 95913 cannot be verified. The required primary service code (code 95913) is denied, therefore,
code 95886 cannot be reimbursed separately. Lastly, the documentation submitted did not include
documentation of needle electromyography using single fiber electrode, with quantitative measurement of
jitter, blocking and/or fiber density, any/all sites of each muscle studied; therefore, code 95872 cannot be
verified.
Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies, the
needle electromyography services, and the needle electromyography using single fiber electrode services have
not been met. Therefore, we decided that the Plan does not have to pay for the nerve conduction studies coded
95913, the needle electromyography services coded 95886, and the needle electromyography using single fiber
electrode services coded 95872 provided from June 24, 2019 to July 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat
exchanger services coded 99190 provided on July 15, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger services.
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the
services billed are not a covered benefit.
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 99190 is Assembly and operation of pump with
oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour.
We find that CPT code 99190 is not supported in the medical record. Specifically, the enrollee received these
services in the facility during inpatient hospitalization. Payment for this service is included in the DRG
payment to the facility. Payment for this service is the responsibility of the facility to any vendor. Based on this
information, we decided that Medicare rules for coverage of the assembly and operation of pump with
oxygenator or heat exchanger services have not been met. Therefore, we decided that the Plan does not have to
pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided
on July 15, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the chronic care management services rendered to you on June 26, 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 that only certain physician specialists can bill code 99490.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the services at issue, billed with code 99490, cannot be paid when billed by a pain management specialist; however, the Plan has not provided any Medicare rules to support this denial. The Plan references the Chronic Care Management Services document, but this document does not specifically exclude the billing of code 99490 by a pain management specialist. The document states that the code is not within the scope of practice of clinical psychologists, podiatrists, or dentists. The Plan has not provided any documentation to support that this code is not payable as billed. Therefore, we decided that the Plan has to pay for the chronic care management services rendered to you on June 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new CPAP device.
You asked the Plan to pre-approve a new CPAP device. You say that your CPAP device was spitting water, even after multiple adjustments, and is old and obsolete. The Plan denied your request. The Plan says there is
no evidence your CPAP was malfunctioning and could not be repaired, or that you are compliant and benefiting from the CPAP.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have CPAP device. This CPAP device serves the same purpose as a new CPAP device. There is no documentation of your CPAP compliance or that it cannot be repaired. Therefore, we decided that the Plan does not have to pre-approve a new CPAP device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic
procedure coded 95999 provided on October 12, 2018.
You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic procedure. You say that
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services
billed are not supported by the documentation.
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 95999 is Unlisted neurological or neuromuscular
diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the documentation submitted
does not support that this code was performed. The documentation supports that train of four
testing/monitoring was performed which does not meet guidelines of code 95999. Based on this information,
we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic
procedure have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted
neurological or neuromuscular diagnostic procedure coded 95999 provided on October 12, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brukinsa 80mg capsules.
You asked the Plan to pre-approve the Brukinsa capsules. You say that the enrollee needs this medication due to his special type of lymphoma. The Plan denied your request. The Plan says this oral drug is not covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. This oral anti-cancer drug does not have an injectable form meaning it is not covered under Part B. Therefore, we decided that the Plan does not have to pre-approve Brukinsa 80mg capsules.
Benefits for the Brukinsa capsules 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from June 14, 2019 through July 13, 2019.
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from June 14, 2019 through July 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided from July 22,
2019 to August 5, 2019.
You asked the Plan to pay for the physician services. You say that you are not aware of what insurance the
enrollee had when you saw her. The Plan denied your request. The Plan says authorization was not obtained
before the services were provided to the enrollee. The Plan also says the services were not urgent or emergent.
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 rendering facility is not a
network provider either. 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 subsequent nursing facility care provided from July 22, 2019 to August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral ankle-foot orthoses (L1971) provided to the enrollee on March 29, 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 bilateral ankle-foot orthoses (L1971) provided to the enrollee on March 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services.You asked the Plan to pre-approve the physician's services. You say that you have seen two different in-network surgeons who have given you three different treatment plans, which has caused you confusion. You say you would like a diagnosis and a treatment plan from a doctor outside of the Plan so you can decide which treatment plan is correct. The Plan denied your request. The Plan says you 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested providers in this case are not network providers with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 13, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says services could have been provided on an observation basis.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided medical records do not indicate medical instability necessitating admission. Care at the observation level appears to have been appropriate for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose monitor (E2100) blood glucose/reagent strips
(A4253) lancets (A4259) calibrator solution/chips (A4256) spring powered device for lancet (A4258) provided
by HNC Medical Supplies LLC July 31, 2019 to October 19, 2019.
You asked the Plan to pay for the diabetic supplies. You say that the records provided should support the
necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the
items billed.
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 proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof of
Delivery include an order number or details to corroborate the Delivery Ticket submitted. Of note, the Proof of
Delivery is not itemized to indicate the specific supplies Therefore, we decided that the Plan does not have to
pay for blood glucose monitor (E2100) blood glucose/reagent strips (A4253) lancets (A4259) calibrator
solution/chips (A4256) spring powered device for lancet (A4258) provided by HNC Medical Supplies LLC
July 31, 2019 to October 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Farxiga tablets.
You asked the Plan to pre-approve Farxiga. You say that you are appealing. The Plan denied your request. The
Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part
B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Farxiga tablets.
Benefits for Farxiga 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional acupuncture services.
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says the enrollee has exhausted the benefit.
The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file, and Medicare rules. The file shows that at the time of request, the enrollee had used the 24 visits allotted for the year. Based on this information, we decided that the plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve additional acupuncture services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam D0140) upper partial denture - resin base (D5211) lower partial denture - resin base (D5212) provided on April 5, 2019.
You asked the Plan to pay for the dental services. You say that the doctor did a bad job and now wants to charge you and the health plan says it is not paying. The Plan denied your request. The Plan says this request exceeds the benefit limit. There is no coverage for dentures under the plan benefits.
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. This plan does not have denture benefits and is therefore not covered. Oral exams are limited to twice a year. Records show this was provided January 23, 2019 and February 15, 2019. 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 limited oral exam D0140) upper partial denture - resin base (D5211) lower partial denture - resin base (D5212) provided on April 5, 2019.