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

We decided that the Plan does not have to waive the copayment forlaboratory testing provided on September 14, 2020.You asked the Plan to waive the copayment forlab tests. You say that these tests were done for your yearly physical.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 $10 copayment for in-network lab services. You have been asked to pay $10 copayment for lab tests. Lab tests fall 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 forlaboratory testing provided on September 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided from June 15, 2020 to June 16, 2020.You asked the Plan to pay forthe self-administered drugs. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the self-administered drugs you received are not covered under your Medicare Part B benefit.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 pay forthe self-administered drugs provided from June 15, 2020 to June 16, 2020.Benefits for the self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of extremity veins (93970) performed on June 24, 2020.

You asked the Plan to waive the copayment for an ultrasound of extremity veins. You say that this service was part of your preventive care. The Plan denied your request. The Plan says the correct copayment was applied.

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 $110 copayment for each Medicare-covered radiological diagnostic service, not including X-rays. 

You have been asked to pay a $110 copayment for an ultrasound of extremity veins. An ultrasound of extremity veins falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This service is not identified as a preventive service in the Plan contract. 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 an ultrasound of extremity veins (93970) performed on June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a raised toilet seat (E0244, E0247, E0243).
You asked the Plan to pay for a raised toilet seat. You say that the devices are necessary to mitigate risk for falls and ensure safe performance of self-care tasks. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a raised toilet seat (E0244, E0247, E0243).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing provided on June 2, 2020.You asked the Plan to pay forthe genetic testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The genetic test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.In addition, these services should be billed with code 81479 and with the appropriate DEX Z code entered adjacent in the comment/narrative field. Therefore, we decided that the Plan does not have to pay forthe genetic testing provided on June 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe contact lens fitting (92310) provided on August 20, 2020.You asked the Plan to pay forthe contact lens fitting. You say that the service provided was billed incorrectly.The Plan denied your request. The Plan says the service provided is not covered according to your Plan benefits.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.We looked at the file and the Plan's rules. Although the Plan offers a routine vision service in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Based on this information, we decided that the Plan's rules for coverage of the contact lens fitting have not been met.
Therefore, we decided that the Plan does not have to pay forthe contact lens fitting (92310) provided on August 20, 2020.Your complaint about a potential mistake made when billing for services rendered is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transcatheter mitral valve repair (CPT code 33418) provided on June 16, 2020.You asked the Plan to pay forCPT code 33418. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the Clinical Trial number was not billed as per Medicare guidelines.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. Medicare says Plans shall pay TMVR for MR claim lines billed with CPT code 33418 in a clinical trial only when billed with an 8-digit national clinical trial number. Based on the information provided, the file shows that the claim was not submitted correctly.Therefore, we decided that the Plan does not have to pay forthe transcatheter mitral valve repair (CPT code 33418) provided on June 16, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided to the enrollee on April 18, 2019.
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 this claim was not filed within the required 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 this service was not filed until August 28, 2020 and a valid waiver was not submitted until October 16, 2020. 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 outpatient services provided to the enrollee on April 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 6, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that these services were medically necessary.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 did not pre-approve the service 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 forthe medical services provided on February 6, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 10, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that you were not aware that authorization was required for this service.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 careand pre-approved care.The provider in this case is not a network provider with the Plan. 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 forthe medical services provided on August 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services provided on May 6, 2020 to June 10, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe chiropractic services. You say that you were not aware that prior authorization was required.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 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 forthe chiropractic services provided on May 6, 2020 to June 10, 2020 by an out of network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from April 20, 2020 to April 23, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received inpatient hospital care on the dates of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $225 copayment per day for days 1-6 for Inpatient hospital care. We looked at the file, the Plan's contract and Medicare rules. The file shows you received observation care from April 17, 2020 through April 20, 2020. You were transferred to inpatient status from April 20, 2020 to April 23, 2020. You have been asked to pay a $225 copayment per day for days 1-4 for the inpatient hospital services, totaling $900. The inpatient hospital services fall within the Inpatient hospital care 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 inpatient hospital services provided from April 20, 2020 to April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea Rituximab injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are other treatments available to help the enrollee's condition.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found Rituximab injections are not indicated as a treatment for Stiff person syndrome as there are not enough studies showing this treatment is effective. The drug's use for this condition would be considered experimental.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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea Rituximab injection for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued home health services.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansayscurrent needs do not appear to be skilled in nature.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonableor necessary. Our physician reviewer found the records do not show that ongoing skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve you condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. You have had prior SN and at this point does not require the ongoing professional skills of a nurse for his wound care or medical needs. There is no evidence of complex wound care or other SN need. The request for additional SN visits is not medically necessary per Medicare Benefit Policy Manual, Chapter 7.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of theservices have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forunlisted procedure, nervous system services coded 64999 provided on June 1, 2020.You asked the Plan to pay forunlisted procedure, nervous system services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.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 64999 is unlisted procedure, nervous system.We find that CPT code 64999 is not supported in the medical record. Specifically, this code should be billed by an anesthesia practitioner. Anesthesia services must be billed with 00100-01999 when billed by an anesthesia practitioner who may be a physician, a certified registered nurse anesthetist (CRNA) with or without medical direction, or an anesthesia assistant (AA) with medical direction. Based on this information, we decided that Medicare rules for coverage of unlisted procedure, nervous system services have not been met.Therefore, we decided that the Plan does not have to pay forunlisted procedure, nervous system services coded 64999 provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for needle electromyography studies (EMG) of anal or urethral sphincter, any technique (51785) and needle electromyography; 2 extremities with or without related paraspinal areas (95861) provided to the enrollee.
You asked the Plan to pay for this treatment. You say that this procedure was medically necessary. The Plan denied your request. The Plan says that Medicare coverage criteria were not met.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of procedure. We asked our Physician Reviewer to look at the case file and the medical rules. Our physician reviewer found the records show the enrollee had L2 pathological fracture. The enrollee underwent hardware removal at L2-L5 and fusion T10-L3. The provider is requesting coverage of nerve conduction studies (51785) Needle Electromyography Studies (EMG) of Anal or Urethral Sphincter, any technique (95861) needle electromyography; 2 extremities with or without related paraspinal areas. The Intraoperative Neuromonitoring/ Ancillary services records were reviewed. The provider was requested to assist in surgery by the operating surgeon. The review has determined that the enrollee had an indication for the services at issue (L2 pathological fracture, underwent hardware removal at L2-L5 and fusion T10-L3). The services were medically necessary and reasonable. LCD coverage criteria were met. We looked at this physician's review, the file, and Medicare rules. Based on this information, Medicare coverage criteria for the services provided were met. Therefore, we decided that the Plan has to pay for needle electromyography studies (EMG) of anal or urethral sphincter, any technique (51785) and needle electromyography; 2 extremities with or without related paraspinal areas (95861) provided to the enrollee June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood bank physician services coded 86077 provided on August 25, 2020.
You asked the Plan to pay for the blood bank physician 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 payable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 86077 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the blood bank physician services have not been met. Therefore, we decided that the Plan does not have to pay for the blood bank physician services coded 86077 provided on August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora power wheelchair with accessories provided on June 10, 2020.You asked the Plan to waive the coinsurance forpower wheelchair. You say that you feel that it is an undue burden for you to pay this amount.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for power wheelchair with accessories. The allowed amount of this claim is $3,027.91, resulting in a coinsurance obligation of $605.57.You have been asked to pay 20% coinsurance for power wheelchair. Power wheelchair falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means thatyou 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 coinsurancefora power wheelchair with accessories provided on June 10, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L0651 and L3960) provided to the enrollee on August 26, 2020.
You asked the Plan to pay for the orthoses. You say that the devices are necessary. The Plan denied your request. The Plan says the submitted documentation did not include 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 does not contain a proof of delivery which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for orthoses (L0651 and L3960) provided to the enrollee on August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dental services provided on May 11, 2020.
You asked the Plan to waive the coinsurance for the dental services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says they originally denied your claim due to the provider being privately contracted. The Plan says that they confirmed that you were not properly informed that you must see a provider that accepts Medicare and the Plan reprocessed your claim and made payment to you, applying your 50% coinsurance to the claim.
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. We looked at the file, the Plan's contract and Medicare rules. The file shows that the Plan originally denied your claim due to the provider being privately contracted. The Plan has now reprocessed this claim for payment applying your 50% coinsurance per your contract with the Plan correctly. Therefore, we decided that the Plan does not have to waive the coinsurance for the dental services provided on May 11, 2020.