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

We decided that the Plan does not have to waive the copayment for laboratory services.

You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges because you have never been charged in the past. 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 $10 copayment for laboratory tests.

You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall 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 laboratory services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for routine eyewear provided on November 13, 2020.
You asked the Plan to pay for eyewear. You say that you feel that the Plan did not pay its $300 allotment toward your glasses. The Plan denied your request. The Plan says the denial of additional payment is correct, because the Plan has paid the full $300 allowance for routine eyewear.
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 routine eyewear up to $300 every 12 months. We looked at the file and the Plan's rules. The Plan has reimbursed the full $300 benefit for routine eyewear. Based on this information, we decided that the Plan's rules for coverage of eyewear have not been met. Therefore, we decided that the Plan does not have to pay for routine eyewear provided on November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on October 5, 2020.
You asked the Plan to pay for the ConfirmMDx testing. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that ConfirmMDx testing is covered for the indications established in the applicable LCD.
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 ConfirmMDx testing. Our reviewer says that the requested ConfirmMDx testing is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 76-year-old man with an elevated prostate specific antigen. A biopsy was performed in October 2020 which showed clinical stage T1c prostate cancer. In this case, the enrollee has a biopsy that demonstrates cancer. The elements of the LCD are not satisfied. 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 ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient clinic visit.

You asked the Plan to pay for the hospital outpatient clinic visit. 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 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 hospital outpatient clinic visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for routine eyewear purchased on September 15, 2020.
You asked the Plan to pay for routine eyewear. You say that you were not aware that this provider was out-of-network. The Plan denied your request. The Plan says the denial of payment for this routine eyewear is correct, because this provider is out-of-network with 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 routine eyewear when obtained from an in-network provider. We looked at the file and the Plan's rules. The Plan only covers routine eyewear obtain from an in-network provider. This eyewear was purchased from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of routine eyewear have not been met. Therefore, we decided that the Plan does not have to pay for routine eyewear purchased on September 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) provided on November 12, 2020. You asked the Plan to waive the copayment for MRI. You say that you needed this imaging but are not financially able to pay this amount. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. 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 $265 copayment for in-network MRI. You have been asked to pay $265 copayment for MRI. MRI 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 Magnetic Resonance Imaging (MRI) provided on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the surgical extractions (D7210 x 3) provided on October 1, 2020.
You asked the Plan to pay the in network rate for the periapical x-ray and 1 additional extractions. You say that you were advised by a plan representative on September 31, 2020, that the provider was in network. You say that you called the plan again when you received your claim summary that said the provider was out of network. You say that you were advised the provider was in network until October 3, 2020 and the claim would be reprocessed. You also say that you did not have any teeth extracted in 2020. The Plan denied your request. The Plan says 1 periapical x-ray per calendar year. The Plan says that 2 extractions are covered per calendar year. The Plan also says that the frequency limits for these services have been exceeded.
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 frequency limits for these services have been exceeded. The record shows that the Plan paid for a periapical x-ray that you received on July 30, 2020. The record shows that the Plan paid for 2 extractions that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the surgical extractions (D7210 x 3) provided on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement Group 3 power wheelchair (PWC).
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 covered.
The Plan must follow Medicare rules. Medicare rules say that DME may be replaced in instances of irreparable damage or exceeding the reasonable useful lifetime period. We looked at the file and Medicare rules. The file shows that the enrollee's current PWC has not exceeded the reasonable useful lifetime period of five years and is not irreparably damaged. The cost of repairs to the current PWC would not be more expensive than a replacement PWC. 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 replacement Group 3 power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiac device monitoring.

You asked the Plan to pay for the cardiac device monitoring. The Plan denied your request. The Plan says that the services were not referred by a network provider or rendered in a participating facility. 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 cardiac device monitoring. 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 cardiac device monitoring.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that it is felt this screening is needed due to his pack-year smoking history. The Plan denied your request. The Plan says the enrollee quit smoking more than 15 years ago. This means that the screening does not meet Medicare coverage rules.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria listed in the Medicare rules section. We reviewed the file and the Medicare rules. We find that you are not a current smoker and you quit more than 15 years ago. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The enrollee is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's physical function is at or near their baseline and they can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 8, 2020 and October 21, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is an absence of 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 physician's services. 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 provided on October 8, 2020 and
October 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on August 3,
2020.
You asked the Plan to waive the copayment for the breast ultrasound. You say that this service was not actually
done, so you shouldn't have to pay this copayment. The Plan denied your request. The Plan says you were
charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for basic imaging services such as x-rays and ultrasounds.
The medical records from this date of service confirm that you had an ultrasound of your right breast on this
date of service. You have been asked to pay a $40 copayment for the breast ultrasound. The breast ultrasound
falls within the basic imaging 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 copayment for
the breast ultrasound you had on August 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria have not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on October 28, 2020.
You asked the Plan to pay for the laboratory test. You say that this test is not available through any other laboratory. You say that the claim should be reprocessed as in-network. The Plan denied your request. The Plan says this provider is not a network with 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 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 laboratory test provided by an out-of-network provider on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services rendered on November 24, 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 claim was not filed timely.
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 these services was not filed until December 23, 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 the emergency room services rendered on November 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrodesis services coded 28730 and the bone graft services coded 20902 provided on June 18, 2020.
You asked the Plan to pay for the arthrodesis services and the bone graft 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 supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 28730 and 20902 are not supported in the medical record. Specifically, the operative report did not include documentation of a multiple or transverse arthrodesis of the midtarsal or tarsometatarsal; therefore, code 28730 cannot be verified. The operative report did not include documentation of a major or large bone graft, any donor area; therefore, code 20902 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the arthrodesis services and the bone graft services have not been met. Therefore, we decided that the Plan does not have to pay for the arthrodesis services coded 28730 and the bone graft services coded 20902 provided on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on December 14, 2020.
You asked the Plan to pay for the nurse practitioner services. 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 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 nurse practitioner services provided on December 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing for blood disorders (BCR/ABL and ABL1) represented by codes 81206, 81207, 81208, and 81170.
You asked the Plan to pre-approve the genetic testing. You say that a BCR/ABL is needed in order to assess whether the enrollee has a genetic mutation that might be causing his abnormal blood counts. You say that results of this test will determine long term medical management of any myeloproliferative disorders of malignancies. You say that the clinical documentation provided supports the need for the requested testing. The Plan denied your request. The Plan says the documentation provided does not show that the enrollee has symptoms of myeloid leukemia or other specific disease of the blood. The Plan says that there is no indication for testing at this time.
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 genetic testing. Our reviewer says that the requested genetic testing is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has an elevated neutrophil count of 9200 and a low lymphocyte count of 600. The hemoglobin, platelet count and MCV are within normal limits. The oncologist ordered PCR for BCR to rule out a clonal process. The enrollee's medical history is notable for diabetes, hypertension, atrial fibrillation, and COPD. BCR/ABL is indicated in patients with suspected chronic myelogenous leukemia with either persistent, unexplained leukocytosis or thrombocytosis. The enrollee in this case does not have unexplained leukocytosis or thrombocytosis. BCR/ABL is considered medically necessary in the evaluation of individuals with chronic myelogenous leukemia or BCR-ABL positive acute lymphoblastic leukemia to evaluate treated individuals who manifest suboptimal response to initial tyrosine kinase inhibitor therapy or loss of response to tyrosine kinase inhibitor therapy. The enrollee does not have a diagnosis of chronic myelogenous leukemia or BCR-ABL positive acute lymphoblastic leukemia. 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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing for blood disorders (BCR/ABL and ABL1) represented by codes 81206, 81207, 81208, and 81170.