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

We decided that the Plan does not have to pay for the laboratory services coded 88307, 88305, and 88342.

You asked the Plan to pay for the laboratory 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 providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT codes 88307, 88305, and 88342 are not supported in the medical record. Specifically, these
services are bundled to another service billed on the same date of service, by the same physician or a physician
of the same specialty in the same group. Based on this information, we decided that Medicare rules for
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay
for the laboratory services coded 88307, 88305, and 88342.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray.

You asked the Plan to waive the copayment for an X-ray. You say that you did not receive an X-ray. 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 a $20 copayment for X-rays.

The medical records show that you received an X-ray. Therefore, you are responsible to pay the $20 copayment.

You have been asked to pay a $20 copayment for an X-ray. An X-ray 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 an X-ray.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay the provider for chiropractic services other than manual manipulation of the spine.

You asked the Plan to pay the provider for services other than manual manipulation of the spine. You say that the Plan should cover all services from a chiropractor as they are helpful to your condition and you do not believe in medication. The Plan denied your request. The Plan says you are currently not being billed for services not covered by the Plan. The Plan has informed the provider of what should and should not be billed. The Plan says that if you are being billed for or have paid out of pocket for non-covered services, that is an issue between you and the provider. The Plan states that the only services covered by the Plan are those codes related to manual manipulation of the spine.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The provider records and explanation of benefits show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay the provider for chiropractic services rendered other than manual manipulation of the spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the specialist office visits.

You asked the Plan to reduce the copayments for the specialist office visits. You say that you believe the visits should have the same copayment as your primary care provider. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copayment for provider and professional services at an in-network specialist's office.

The enrollee has been asked to pay a $35.28 copayment, which is less than the standard amount, for the specialist office visit. The enrollee has also been asked to pay a $45 copayment for the specialist office visit. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were seen by a nurse practitioner at a urology office which is considered a specialty.

This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the copayments for the specialist office visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466).

You asked the Plan to pre-approve a non-invasive home ventilator. You say that the requested care is necessary for the enrollee. The Plan denied your request. The Plan says the requested item is not medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 a non-invasive home ventilator. Our reviewer says that the requested item is not medically necessary. Our physician reviewer found that the enrollee had a recent hospitalization for acute on chronic Hypercarbic respiratory failure. Pulmonary function tests do not support a diagnosis of COPD. The enrollee is morbidly obese and most likely has Obesity hypoventilation syndrome. The treatment is continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). Medicare does not cover a ventilator when used as BiPAP.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a non-invasive home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthoses (L1833 L2397).

You asked the Plan to pay for the knee orthoses. You say that you would like reconsideration because these orthoses are medically necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and ordering physician.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the knee orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not indicate that the enrollee has had a recent injury or surgical procedure. The documentation indicates subjective description of joint instability. The provided documentation does not credibly establish that an in-person examination occurred.

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 knee orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthoses (L1833 L2397).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that the medics lifted you up from a wood pile.
The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. 
When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, bitewing x-rays, first intraoral periapical x-ray, and two periodontal scalings and root planings, and to pay for the additional intraoral periapical x-ray provided by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, first intraoral periapical x-ray, and two periodontal scalings and root planings, or pay for the additional intraoral periapical x-ray. You say that you were not advised that this provider was OON. You also say that you cannot afford to pay for these services. The Plan denied your request. The Plan says benefits for the additional intraoral periapical x-ray have been satisfied and the frequency limitation has been exceeded. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services provided OON.

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, intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray which was covered by the Plan, and your intraoral x-rays benefit had been exhausted. You are also responsible for the OON copayments plus the difference between the billed amount and the maximum allowable fee for services rendered OON. The record also shows that you did not contact the Plan prior to the date of service to verify provider eligibility.

Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, bitewing x-rays, first intraoral periapical x-ray, and two periodontal scalings and root planings, and to pay for the additional intraoral periapical x-ray provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a continuous glucose monitor.

You asked the Plan to provide a continuous glucose monitor. You say that a CGM works best and to monitor with testing strips is not something you should have to do when there are better options available for glucose testing. The Plan denied your request. The Plan says you do not use insulin.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro 2 Motion G Orthotic device (L8702).

You asked the Plan to pre-approve MyoPro 2 Motion G Orthotic device. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for your health problem.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 MyoPro 2 Motion G orthotic device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 74-year-old female who suffered a stroke. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MyoPro 2 Motion G orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro 2 Motion G orthotic device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee.

You asked the Plan to pay for the services. You say that H0004 is payable code. The Plan denied your request. The Plan says there was no valid 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 rendering provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 office visit services provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the chest with computed tomography angiography for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation does not provide any information to any worsening symptoms.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found a repeat CT angiogram of the chest is considered not medically necessary. The enrollee had a pulmonary embolism (PE) complicated COVID infection. She now needs elective orthopedic surgery and the question is whether anticoagulation can be safely discontinued, A repeat CT angiogram will not help with that decision. The amount of residual clot in the pulmonary vasculature has not been shown to be a predictor of risk for recurrent PE. There would be no clinical benefit to this imaging.

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the chest with computed tomography angiography for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for an inpatient hospital stay provided by a participating provider.

You asked the Plan to waive the deductible and copayment for an inpatient hospital stay. You say that you were in-network and you thought the Plan would pay more. The Plan denied your request. The Plan says the correct deductible and copayment have been 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 $1,000 deductible and a $750 copayment for inpatient hospital care/in-network.

You have been asked to pay a $1,000 deductible and a $750 copayment for an inpatient hospital stay. The total amount you are being asked to pay is $1,750 ($1,000 deductible + $750 admission fee = $1,750). An inpatient hospital stay falls within the inpatient hospital care/in-network 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 deductible and copayment for an inpatient hospital stay provided by a participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery, laboratory services, or waive the cost share for the self-administered drugs.

You asked the Plan to waive the copayment for the outpatient surgery and laboratory services, and waive the cost share for the self-administered drugs. You say that you contacted the Plan and were advised you could only be charged $325 for these services. The Plan denied your request. The Plan says the copayment amount you are being charged for the outpatient surgery and labs is correct. The Plan also says that the remainder of the cost share, $222.36 was for self-administered medications, which will fall under your Part D coverage, not your medical coverage.

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 per day, per provider, for Medicare-covered lab services, and a $250 copayment for each Medicare-covered outpatient hospital facility visit for Outpatient hospital services and Outpatient diagnostic tests and therapeutic services and supplies. The rules also say that Medicare Part B generally does not pay for self-administered drugs.

You have been asked to pay a $10 copayment per day, per provider, for Medicare-covered lab services, and a $250 copayment for each Medicare-covered outpatient hospital facility visit for outpatient surgery and laboratory services. Outpatient surgery and laboratory services falls within the Outpatient hospital services and Outpatient diagnostic tests and therapeutic services and supplies benefit categories. 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. Also, 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 waive the copayment for outpatient surgery, laboratory services, or waive the cost share for the self-administered drugs.

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 hospital services.

You asked the Plan to pay for hospital services. You say that you originally submitted a claim. The Plan denied your request. The Plan says the denial of payment for this claim is correct, because this claim was not submitted within the timely filing limit.

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 hospital services was not filed until November 17, 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 hospital services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require the intensity of services provided at an
IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and
regular physician evaluation. The enrollee's care needs can be met at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy and Orthotic(s) management and training.

You asked the Plan to pay for the manual therapy and Orthotic(s) management and training. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 manual therapy and Orthotic(s) management and training.