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

We decided that the Plan has to pre-approve the requested diabetic test strips.
You asked the Plan to pre-approve the requested diabetic test strips. You say that the requested diabetic test strips are medically necessary. The Plan denied your request. The Plan says that the requested diabetic test strips fall under the enrollee's Medicare Part B benefit.
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. Specifically, the request is for diabetic test strips, which fall under the enrollee's Medicare Part B benefit. The Plan denied the requested diabetic test strips stating the case was classified as a Part D case due to being a Part D benefit denial. The Plan has not provided any information in regards to why the requested diabetic tests strips would not be covered under the enrollee's Medicare Part B benefit. We do not have jurisdiction to review Part D denials. We find the Plan has not substantiated their reasoning for denial of the diabetic test strips under the enrollee's Medicare Part B benefit. Therefore, we decided that the Plan has to pre-approve the requested diabetic test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) rendered to you on November 21, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services exceed the coverage limit.
The Plan must follow Medicare rules. The rules say that no more than two (2) thermal RF ablation sessions may be reimbursed per spinal region per rolling 12 month year. We looked at the file and Medicare rules. The file shows that you received two RFA treatments on May 16, 2019 and June 27, 2019 for which the Plan approved and paid. The services on November 21, 2019 exceed the limit of two sessions per spinal region per 12 months. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation (RFA) rendered to you on November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the gene analysis provided on November
29, 2019.
You asked the Plan to waive the coinsurance for the gene analysis. You say that you were not informed a large
charge could apply. You say that you would not have done the test if you knew beforehand. The Plan denied
your request. The Plan says the coinsurance 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 20%
coinsurance for molecular and predisposed genetic testing.
You have been asked to pay $640, which is 20% of the allowed amount for the gene analysis. The allowed
amount is $3,200 (20% x $3,200 = $640). The gene analysis 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 coinsurance for
the gene analysis provided on November 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for the Novolog 100 unit/ml vial drug (J1815).
You asked the Plan to pre-approve the tier exception. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that the drug requested is covered under the Medicare Part B (medical) benefit. Tier exceptions are only possible for certain Part D drugs. A tier exception cannot be granted for the Part B medication.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met. Specifically, the record indicates that the drug at issue is being covered by the Plan under Medicare Part B. Part B Drugs are not eligible for tier exceptions. Therefore, we decided that the Plan does not have to pre-approve a tier exception for the Novolog 100 unit/ml vial drug (J1815).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal attendant services.
You asked the Plan to pre-approve personal attendant services. You say that you are not able to do things on your own. The Plan denied your request. The Plan says these services are not covered by medicare.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. The rules also say that custodial care is not covered. We looked at the file and Medicare rules. The record does not indicate that you have skilled nursing or therapy needs. The requested services are custodial in nature. Based on this information, we decided that Medicare rules for coverage of personal attendant services have not been met. Therefore, we decided that the Plan does not have to pre-approve personal attendant services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty, multiple braking system, variable wheel resistance walker (E0147).
You asked the Plan to pre-approve these services. You say that you prefer this walker over a standard walker. The Plan denied your request. The Plan says that you do not have a severe neurologic disorder or other condition causing the restricted use of one hand.
The Plan must follow Medicare rules. Medicare rules say that a heavy duty, multiple braking system, variable wheel resistance walker is only covered if you are unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand. We looked at the file and Medicare rules. The file does not indicate you are unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty, multiple braking system, variable wheel resistance walker (E0147).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the microfluidanalysis of tears provided by the Doctor on November 15, 2019.You asked the Plan to waive the copayment forthe microfluid analysis of tears. You say that you feel that the charges should be included in your office copayment.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 $5 copayment for diagnostic lab services. You have been asked to pay a $5 copayment for the microfluid analysis of tears. The microfluid analysis of tears 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 forthe microfluid analysis of tears provided by the doctor on November 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 9, 2019 to the enrollee by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe medical services provided on October 9, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on July 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is
no eligible to bill for assistant surgeon services.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services
provided on July 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on July 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 physician services provided on July 26, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composite for one surface on a posterior tooth (D2391) provided on December 3, 2019.You asked the Plan to pay for the dental service. You say that this is the tooth that holds your partial denture in and therefore would be covered.The Plan denied your request. The Plan says the resin based composite is not a covered service.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 resin based composite is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe resin based composite for one surface on a posterior tooth (D2391) provided on December 3, 2019.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for the presumptive and definitive drug testing panels. We decided that the Plan does not have to pay for the individual assays for six other drugs. You asked the Plan to pay for the presumptive and definitive drug testing panels. You say that this testing was supported by the medical records and was ordered by the treating physician. The Plan says that the order provided is signed but not dated so it is not a valid order. We decided that the Plan has to pay for the presumptive and definitive drug testing panels. The Plan follows Medicare rules. Medicare rules say that laboratory testing may be covered by the treating provider. In this case, the file contains an order form from the enrollee's in-network provider which clearly indicates that both presumptive screening and definitive testing of 22 or more drug classes was requested. We find that the denial rationale that there is no valid order is not supported. Lab orders are not required to be signed and there
is no evidence that the Plan attempted to obtain records from its network physician or requested records from the laboratory to support that these tests were not intended by the physician. The laboratory provider cannot be expected to provide documentation which not requested, is within the control of the Plan, and is not clearly required to support the appeal based the claim denial rationale. Therefore, we decided that the Plan has to pay for the presumptive and definitive drug testing panels. We also decided that the Plan does not have to pay for the individual assays for six other drugs. The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The billed code of G0483 includes testing of 22 or more drug classes. There is no indication in the record that these separately billed tests would not be included as one of the 22 or more drug classes reported via G0483.
Therefore, we decided that the Plan does not have to pay for the individual assays for six other drugs.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on April 8, 2019.
You asked the Plan to pay for the laboratory services. 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 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 laboratory services provided on April 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total electric hospital bed (E0265). You asked the Plan to pre-approve total electric hospital bed. You say that you are unable to walk, have nose bleeds, heart failure and multiple surgeries for hemorrhaging. You cannot use a manual or a semi bed. The Plan denied your request. The Plan says this item is not a covered benefit. The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve total electric hospital bed (E0265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction (92015) frames (V2020) lenses (V2100) provided September 12, 2019.
You asked the Plan to pay for the vision services. You say that prior authorization was not obtained because the provider does not know which patient he'll see since he is assigned to a facility and is given a chart of patients in need of services. The Plan denied your request. The Plan says vision services received at a non-network optical provider are not covered by the plan.
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. The Plan covers these services when rendered by an in-network provider.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for eye refraction (92015) frames (V2020) lenses (V2100) provided September 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea heavy duty manual wheelchair (K0006).You asked the Plan to pre-approvethe heavy duty manual wheelchair. You say that the wheelchair is necessary to allow transport to and from appointments.The Plan denied your request. The Plan says the record shows you already have a power scooter for use in the home. The requested wheelchair is for use primarily outside the home.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea heavy duty manual wheelchair (K0006).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Coaguchek machine provided from September 9, 2019 through November 4, 2019 by an in-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). You are responsible for $18.46 per date of service on September 09, 2019, October 07, 2019 and November 04, 2019; totaling $55.38. 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 the Coaguchek machine provided from September 9, 2019 through November 4, 2019 by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from September 4, 2019 through September 9, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that the enrollee was admitted on September 4, 2019 and discharged on September 9, 2019. The enrollee was asked to pay a $275 copayment per day from September 4, 2019 through September 8, 2019, days 1-5 of their inpatient stay. There were no copayment charges on their day of discharge, September 9, 2019. Per the enrollee's contract there is a $275 copayment per day required for days 1-5. 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 waive the copayment for inpatient hospital care provided to the enrollee from September 4, 2019 through September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker and attachments for the enrollee.
You asked the Plan to pre-approve a walker and attachments. You say that the enrollee would benefit from
having a rollator. The Plan denied your request. The Plan says that the enrollee was provided with a walker in
2018.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no
case can be less than five years. The enrollee received a walker in 2018, which is less than five years ago.
Therefore, we decided that the Plan does not have to pre-approve a walker and attachments for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room Care (99283) provided August 31, 2019. You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with a code already paid. 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, we have confirmed that code 99283 has a bundled relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for Emergency Room Care (99283) provided August 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polycarbonate lens (V2784x2) anti-reflective lens (V2750) provided August 8, 2019.
You asked the Plan to pay for the eyeglasses and lenses. You say that you have not received your benefit reimbursement. The Plan denied your request. The Plan says the maximum amount of the eye wear allowance was paid to the provider for this service. The remaining amount is the additional features to the eye wear.
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. The Plan covers these services when $200 for eye wear every year. You are responsible for any amount above the eye wear coverage limit. We looked at the file and the Plan's rules. $200 for eye wear every year. You are responsible for any amount above the eye wear coverage limit. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses and lenses have not been met. Therefore, we decided that the Plan does not have to pay for polycarbonate lens (V2784x2) anti-reflective lens (V2750) provided August 8, 2019.