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

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on December 30, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were placed on a 23-hour observation and was not informed that if you were admitted, the copayment would have been waived. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for emergency services at an in-network emergency room. You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the "Emergency 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 emergency room visit provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on January 28, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the office visit provided on January 20,
2020.
You asked the Plan to reduce the copayment for the office visit. You say that you were not told that the
provider was out-of-network. You say you were under the impression that your provider was in-network and
would be charged the in-network copayment. The Plan denied your request. The Plan says you have been
charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35
copayment for an out-of-network PCP office visits/other health care professionals.
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The record shows the provider is out-ofnetwork.
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 reduce the copayment for the office visit provided on January 20, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the home health services. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent
to seek out-of-network care. The Plan has approved the enrollee for four visits with an in-network provider.
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 that cannot be provided by network providers.
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
the home health services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on
December 6, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the
type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to
pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Onetouch ultra blue test strips.
You asked the Plan to pre-approve Onetouch ultra blue test strips. You say that the items are necessary. The
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not
been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 Onetouch ultra blue test strips. Our
reviewer says that the requested items are considered medically reasonable and necessary in this case. Our
physician reviewer found the prescribing doctor has indicated on May 18, 2020 by signing the form that the
enrollee has dexterity issues that require him to use this meter in particular instead of another meter which is
likely preferred by the plan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Onetouch ultra blue test strips have been met. Therefore, we decided that the
Plan has to pre-approve Onetouch ultra blue test strips.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on October 30, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on October 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
October 10, 2019 to October 22, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says report of the FIPS code is required to identify
the county where the services were rendered.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the
submitted claim does not include the required FIPS code. Therefore, we decided that the Plan does not have to
pay for the home health services provided to the enrollee from October 10, 2019 to October 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the VeriStrat testing services provided on May 30, 2019.
You asked the Plan to pay for the testing services. You say that the test was ordered to assist in developing the
treatment plan for the enrollee. The Plan denied your request. The Plan says there are currently no clinical
indications for this technology.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or
provider must corroborate the documentation in the beneficiary's medical documentation.
We looked at the file and Medicare rules. In this case, there were insufficient medical records provided to show
the results of this testing would be used to determine a specific diagnosis or determine a specific treatment
strategy for disease Based on this information, we decided that Medicare rules for coverage have not been met.
Therefore, we decided that the Plan does not have to pay for the VeriStrat testing services provided on May 30,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services provided on September 24, 2019.
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says additional reimbursement is not due.
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 file shows that you received an eye exam and refraction. The documentation shows that the eye exam was provided in relation to age-related cataracts. This means that eye exam is medical in nature. The supplemental vision benefit covers up to $75 toward routine eye exams which include refraction testing. This refraction testing was not provided with a routine eye exam. 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 eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction services provided on September 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided December 6, 2019.
You asked the Plan to pay for the ambulance services. You say that the services should be paid as the paramedics provided care on-scene. The Plan denied your request. The Plan says Medicare only pays for ambulance service when a transport is made.
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 on December 6, 2019. 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 ambulance services provided December 6, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from October 2, 2018 to December 13, 2018.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you met the MOOP amount for the year prior to receiving the services. 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 the MOOP amount for 2018 is $4,900. Your contract with the Plan also clearly says that you must pay a $40 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services from October 2, 2018 to December 13, 2018 for a total of 5 visits. The record shows that you had only paid $3,876 toward the $4,900 MOOP amount. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 5 (outpatient rehabilitation services) = $200. You have been asked to pay the total copayment amount of $200 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 copayments for outpatient rehabilitation services provided from October 2, 2018 to December 13, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675).
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says claims for E0675 will be denied as not reasonable and necessary.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. The rules also state that claims for E0675 will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and sleeves provided to the enrollee on
September 19, 2019.
You asked the Plan to pay for the orthoses and sleeves. The Plan denied your request. The Plan says that the
request is not a covered benefit because records show that the evaluation did not take place at a qualifying
originating site.
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 knee orthoses and
sleeves provided to the enrollee on September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397)
provided to the enrollee on October 31, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with
suspension sleeve (L1851, L2397) provided to the enrollee on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libra Sensor and Reader for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not checking sugars four or more times per day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 monitor. Our reviewer says that the requested monitor is not medically reasonable or necessary. Our physician reviewer found in this case, the member is not checking blood sugars four or more times per day at the present time and does not adjust dosage based upon those readings. The review has determined that the documentation shows that the CGM will be used in place of a blood glucose monitor for the enrollee for making diabetes treatment decisions (for example, changes in diet and insulin dosage). The requested CGM is not medically reasonable or necessary. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5253) purchased October 25, 2019.
You asked the Plan to pay for the hearing aids. You say that you have never bought hearing aids through the
plan. Your old hearing aids died a plan representative said that the provider was in network and that the plan
would reimburse up to $500 per ear. The Plan denied your request. The Plan says this request exceeds the
benefit limit.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only the plan will pay $500 per ear every 5 years. This benefit is limited to once every 5 years.
Records show that this service was provided July 19, 2016.
We looked at this the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for
the hearing aids (V5253) purchased October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression wraps identified with code A6545.
You asked the Plan to pre-approve gradient compression wraps. You say that you need gradient compression wraps for your condition. The Plan denied your request. The Plan says you do not have a qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings/wraps described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve gradient compression wraps identified with code A6545.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 7, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 7, 2020.