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

We decided that the Plan does not have to pre-approve the MarrowSeq Bone Marrow Failure Panel for the enrollee.
You asked the Plan to pre-approve the panel. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this test is helpful for the evaluation of low white blood cell count.
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 the panel. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found while the requested test may identify an underlying genetic cause of the enrollee's leukopenia, it is not shown that the test would affect the presence or treatment of the enrollee's leukopenia. Therefore, the requested test is not shown to be medically necessary or reasonable. 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 panel have not been met. Therefore, we decided that the Plan does not have to pre-approve the MarrowSeq Bone Marrow Failure Panel for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on February 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on February 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from December 30, 2019 to January 7, 2020.You asked the Plan to waive the copayment for the SNF stay. You say that you do not have the money to pay the copayment. You say you were not notified there would be a 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 $20 copayment per day for days 1-20 of a benefit period for each admission.You have been asked to pay a $20 copayment for each day of the SNF stay. ($20 x 8 = $160). The SNF stay falls within the "Skilled nursing facility (SNF) 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 forthe SNF stay provided from December 30, 2019 to January 7, 2020.Your complaint about the facility's poor care is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis, the ankle foot orthosis, or the knee orthosis and suspension sleeve provided on January 12, 2020.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960), the ankle foot orthosis (L1971), the knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthoses were 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 shoulder-elbow-wrist-hand orthosis, the ankle foot orthosis, or the knee orthosis and suspension sleeve provided on January 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound and a specialist office visit provided by a participating provider on January 27, 2020.
You asked the Plan to waive the copayment for an ultrasound and a specialist office visit. You say that you do not believe that you should have to pay for this. The Plan denied your request. The Plan says the correct copayments 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 $25 copayment for outpatient diagnostic tests/peripheral vascular ultrasound and a $35 copayment physician/practitioner services/specialist. You have been asked to pay a $25 copayment for an ultrasound and a $35 copayment a specialist office visit. The total amount you are being asked to pay is $60 ($25 + $35 = $60). An ultrasound falls within the outpatient diagnostic tests/peripheral vascular ultrasound and a specialist office visit falls within the physician/practitioner services/specialist 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 ultrasound and a specialist office visit provided by a participating provider on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.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, the record does not show that the enrollee had at least
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that a SNF is medically necessary for the enrollee's recovery process and so that she does not degrade. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the care needed can be received in another setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee had been on Hospice and revoked services on June 3, 2020. She used oxygen via nasal cannula and was alert with confusion. The enrollee received physical therapy, speech therapy, and occupational therapy in the skilled nursing facility. The enrollee was at a contact guard to minimal assist level with functional mobility including gait to 45 feet with a rolling walker. The enrollee required varying assist with activities of daily living. She tolerated a pureed diet and nectar thickened liquids. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on December 2, 2019.You asked thePlan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the servicesat 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 physician's services that you provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided out of network on February 13, 2020.
You asked the Plan to pay for out of network services. You say that no one told you this provider was out of network. In a letter directly to Maximus, you stated the provider tried to contact the Plan regarding their provider status and did not get a response. The Plan denied your request. The Plan says this provider is not in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says enrollees must use network providers to get routine care and services. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for acupuncture services provided out of network on February 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forframes (V2020) and bifocal lenses (V2220) provided March 1, 2020.You asked the Plan to pay forthe vision services. You say that you were told by the provider to go to your insurance company to be reimbursed for the glasses you purchased. Now you find out that the provider is an out of network provider.The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-networkprovider.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 provided by an in-network provider.We looked at the file and the Plan's rules. Vision services must be rendered by an in-network provider.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 forframes (V2020) and bifocal lenses (V2220) provided March 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on October 8, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that this was a screening colonoscopy. 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 $150 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $150 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows that polyps were removed during your colonoscopy which makes the colonoscopy diagnostic.
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 colonoscopy provided on October 8, 2019.
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 on the date of service you fell while attending the funeral of a close friend. You say that you were asked if you would like an ambulance called however you declined. You stated that someone called for an ambulance anyway and they would not leave until they had seen you. You say that you went to see them in order to get rid of them and the responders immediately started evaluating you. You stated that you signed a waiver that said you refused transport and you just wanted them to leave. You say that you do not believe that you should be responsible for the cost of the services because you did not ask for them and you did not want them. 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 on February 25, 2020. 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.
Your complaint about the ambulance services being unsolicited is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on January 17, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 services at issue in this appeal. 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 forthe medical services provided to the enrollee by an out-of-network provider on January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy, anterior tooth (D3310) provided January 30, 2020.
You asked the Plan to pay for the dental services. You say that this service was medically necessary due to an infection that could have caused other serious medical conditions. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
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 endodontic therapy, anterior tooth (D3310) provided January 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemassage therapy.You asked the Plan to pre-approvethese services. You say that you have pain in your legs, feet, and hands as a result of cancer blocking therapy.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist.Therefore, we decided that the Plan does not have to pre-approvemassage therapy.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on March 13, 2020.You asked the Plan to waive the copayment forthe emergency room visit. You say that you were unaware of the cost share and cannot pay this due to hardship. 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 $110 copayment for each covered emergency room visit. You have been asked to pay a $110 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 contractwith 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 emergency room visit provided on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on January 2, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay forthe drug testing rendered on January 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nuclear stress test.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a nuclear stress test is covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of hypertension and hyperlipidemia. A clinic note dated February 28, 2020 documents no chest pain, no dyspnea, and a normal cardiovascular physical exam. The electrocardiogram on February 28, 2020 and echocardiogram on March 6, 2020 are normal. The enrollee has some coronary risk but no symptoms or objective findings concerning for coronary ischemia. The records do not support that the nuclear stress test is reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. 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 nuclear stress test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the chair purchased on February 24, 2020.
You asked the Plan to reimburse you for the chair. You say that the walker is necessary because it is extremely painful for you to walk any distance. The Plan denied your request. The Plan says you purchased the transport chair without a prescription from your primary care physician. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. Payment cannot be made for items purchased from this provider because this provider is not a medical provider and is not enrolled in Medicare. Therefore, we decided that the Plan does not have to reimburse you for the chair purchased on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on January 2, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed services cannot beverified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on January 2, 2020.