Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the catheters provided from February 19, 2019 to November 25, 2019.You asked the Plan to waive the coinsurance for the catheters. You say that you never received a bill.The Plan denied your request. The Plan says that the claims processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare-covered prosthetic devices and supplies. You have been asked to pay a 20% coinsurance for the catheters. The catheters fall within the Medicare-covered prosthetic devices 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 coinsurance forthe catheters provided from February 19, 2019 to November 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on February 14, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that you were charged twice for the HPV test. You say that you shouldn't have to pay for it. 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 $10 copayment for Medicare-covered lab services. You have been asked to pay a $10 copayment for the laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that a second test was performed. 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 laboratory services provided on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided on November 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient office visit. You say that the DME was necessary from cancer surgery and Home Care and related DME provider do make the DME product. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 office visit provided on November 7, 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 lumbar-sacral orthosis provided on August 29, 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 rules for telehealth services were not met.
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 the lumbar-sacral orthosis provided on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the HAVRIX vaccine received on February 7, 2020.You asked the Plan to pay for the vaccine. You say that this should be reprocessed for payment.The Plan denied your request. The Plan says services determined not effective are not covered.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide for immunizations. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to this vaccine.Therefore, we decided that the Plan does not have to pay for the HAVRIX vaccine received on February 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0480 provided on August 23, 2019.
You asked the Plan to pay for the drug testing. 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 G0480 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. We find that CPT code G0480 is not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition form or medical records stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0480 provided on August 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral exam (D0120) and prophylaxis, cleaning (D1110) provided September 4, 2019.
You asked the Plan to pay for the dental services. You say that you assumed that all covered work done by this office would be approved. You were not told by the office that this provider was not in-network. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodic oral exam (D0120) and prophylaxis, cleaning (D1110) provided September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the abdomen to be provided at the out of
network (OON) facility.
You asked the Plan to pre-approve the OON MRI. You say that you need this imaging as a medical necessity.
The Plan denied your request. The Plan says this imaging can be provided by network providers within a
reasonable distance to your home.
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 care not available within the network.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an MRI of the abdomen to be provided at the out of network (OON) facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) knee orthosis (L1833) and suspension sleeve (L2397) provided October 30, 2019.
You asked the Plan to pay for the orthoses. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines
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 non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) knee orthosis (L1833) and suspension sleeve (L2397) provided October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer 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 physician services provided on January 15, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient hospital facility visit provided on January 15, 2020.
You asked the Plan to waive the coinsurance for an outpatient hospital facility visit. You say that you would not have received the services if you were told the cost ahead of time. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You had an outpatient hospital facility visit on January 15, 2020. The total allowed mount is $4,251.18 and 20% of that is $850.24. You have been asked to pay the total coinsurance amount of $850.24 for an outpatient hospital facility visit. An outpatient hospital facility visit falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 coinsurance for an outpatient hospital facility visit provided on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for deluxe frames (V2025) progressive lens (V2781) and anti-reflective coating (V2750) purchased November 25, 2019.You asked the Plan to pay for the vision services. You say that according to your benefits for 2019, frames, lenses and fitting from out of network was $200 and you received a check for $100.The Plan denied your request. The Plan says that the claim was processed correctly according to page 95 of the 2020 Evidence of Coverage.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $200 eyewear benefit for Vision care. The Plan says you must payfor any amount over the$100 eyewear benefit. Based on the Plan contract, however, you must pay for any amount over the  $200 eyewear benefit.Therefore, we decided that the Plan has to pay for deluxe frames (V2025) progressive lens (V2781) and anti-reflective coating (V2750) purchased November 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs given, while inpatient, from January 1, 2020 to January 3, 2020.You asked the Plan to pay for the self-administered drugs. You say that you had no access to your prescriptions while inpatient.The Plan denied your request. The Plan says self-administered drugs are not covered under your 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 for the self-administered drugs given, while inpatient, from January 1, 2020 to January 3, 2020.Benefits for the self-administered drugs 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 pay for the anticoagulant management services provided on January 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the anticoagulant management services. 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.
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 anticoagulant management services provided on January 28, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for screening ultrasounds provided by on October 4, 2019.
You asked the Plan to pay for screening ultrasounds. You say that you were paid for the same services in the past. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this testing is not a Medicare benefit for the diagnoses billed and was performed for screening purposes.
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 tests at issue in this appeal, screening ultrasounds, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for screening ultrasounds provided on October 4, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the bitewings. We also decided that the Plan does not have to pay for
the five extractions.
You asked the Plan to pay for the bitewings and five extractions. You say that the extractions were medically
necessary and not done for cosmetic reasons. The Plan says that the benefits for extractions have been satisfied
and the frequency limitation has been exceeded.
We decided that the Plan has to pay for the bitewings.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the Plan unless notice is provided that the services will not be covered. The Plan follows these rules. Your dentist provided bitewing x-rays using the code D0204. The dentist is a network provider. Although the code used is not recognized, the contract does cover bitewing x-rays and it is not clear that you were told that these would not be covered. Under Medicare rules, this means the bitewing x-rays are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the bitewings.
We also decided that the Plan does not have to pay for the five extractions.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The Plan contract says that extractions are limited to two procedures per calendar year. The record shows that you received four extractions on January 15, 2020, two of which were covered by the Plan, and your extractions benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the five extractions.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has high grade serous carcinoma of ovary. The documentation supports that MMR is intact. The enrollee was unable to tolerate Olaparib. The documentation does not support that the requested use is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The documentation does not support that the requested drug is approved for the enrollee's diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the second unit of ambulance service provided on November 19, 2019.You asked the Plan to pay fora second ambulance service. You say that the Plan should pay this claim.The Plan denied your request. The Plan says there is no documentation on more than one unit of service.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. There is no Trip Report supporting a second unit of service. Based on this information, we decided that Medicare rules for coverage of a second ambulance service have not been met.Therefore, we decided that the Plan does not have to pay for the second unit of ambulance services provided on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 27, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you received approval to see the provider. You say that it must be paid in-network. 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 $75 copayment for services obtained from an out-of-network specialist. You have been asked to pay a $75 copayment for the office visit. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The records show that the provider is out-of-network. 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 office visit provided on January 27, 2020.