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

We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on January 22, 2020.
You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by physician with written report. We find that CPT code 85060 is not supported in the medical record. Specifically, this code has a code of 8 which means this code is an interpretation code. This indicator identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. No TC billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, generally through the PPS rate. Based on this information, we decided that Medicare rules for coverage of the blood smear services have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear services coded 85060 provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the diagnostic tests, ER visits, office visits,
injections and nail plate removal provided from January 8, 2019 through December 19, 2019.
You asked the Plan to waive the cost share for the diagnostic tests, ER visits, office visits, injections and nail
plate removal. You say that you weren't informed you would have to start paying copayments. You say that
you cannot pay this amount. The Plan denied your request. The Plan says the cost share 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 a $40
copayment for diagnostic procedures and tests, a $90 copayment for emergency care, a $20 copayment for
specialist services and 20% coinsurance for all other drugs covered under Medicare Part B.
You have been asked to pay a total of $1,054.03 for the diagnostic tests, ER visits, office visits, injections and
nail plate removal.
The diagnostic tests fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit
category. The ER visits fall within the "Emergency care" benefit category. The office visits and nail plate
removal fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The
injections fall within the "Medicare Part B prescription drugs" 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 cost share for the diagnostic tests, ER visits, office visits, injections and
nail plate removal provided from January 8, 2019 through December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe non-covered chiropractic services provided on September 10, 2019.You asked the Plan to pay forthe non-covered chiropractic 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 are not covered when provided by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare coversis manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe non-covered chiropractic services provided on September 10, 2019.Your complaint about the Plan approving these services 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 services rendered to you by a chiropractor on August 27, 2019.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 are not covered when performed by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The provider submitted a claim for procedure codes 99203 (office visit) and 97140 (manual therapy techniques).Therefore, we decided that the Plan does not have to pay forthe services rendered to you by a chiropractor on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided to the enrollee on December 12,
2019.
You asked the Plan to pay for the hearing aids. You say that the claim should be paid. The Plan denied your
request. The Plan says there is no coverage for non-participating providers rendering hearing services.
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 enrollee's EOC states, enrollees must use a participating hearing provider to use this benefit. 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 hearing aids provided to the enrollee on December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the glucose monitor and supplies provided on January 7, 2020, February 17, 2020 and March 17, 2020.
You asked the Plan to waive the coinsurance for the glucose monitor and supplies. You say that you should only have to pay $44.55 a month. You say that you don't feel that you owe the balance. 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 Lifescan test strips, diabetic supplies and therapeutic shoes or inserts. Covered services include supplies to monitor your blood glucose: Blood glucose monitor, blood glucose test strips, lancet devices and lancets, and glucose-control solutions for checking the accuracy of test strips and monitors. You have been asked to pay a total of $142.74 for the glucose monitor and supplies.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
January 7, 2020
Glucose Monitor
& Supplies
$222.77
20%
$44.55
February 17, 2020
Glucose Monitor
& Supplies
$222.77
20%
$44.55
March 17, 2020
Glucose Monitor
& Supplies
$268.24
20%
$53.64
TOTAL:
$142.74
The glucose monitor and supplies fall within the "Diabetes self-management training, diabetic 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 glucose monitor and supplies provided on January 7, 2020, February 17, 2020 and March 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chemotherapy administration provided from July 16, 2019 to September 26, 2019. You asked the Plan to waive the copayment for chemotherapy administration. You say that the enrollee had met the out-of-pocket maximum. The Plan denied your request. The Plan says this processed 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for chemotherapy drugs. The enrollee has been asked to pay $181.74, which is less than the 20% coinsurance for chemotherapy administration, because $181.74 remained of the $6,700 out-of-pocket maximum when this claim was processed. 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 chemotherapy administration provided from July 16, 2019 to September 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ForeseeHome diagnostic test. You asked the Plan to pre-approve the requested services. You say that the enrollee's age-related macular degeneration (AMD) is at risk for developing the wet form of AMD. The Plan denied your request. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. In this case, there were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy. The file shows that the Plan made requests for additional records, but none were obtained. 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 pre-approve a ForeseeHome diagnostic test.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray services (R0070, 71045, Q0092) provided on January 23, 2020. You asked the Plan to pay for the portable x-ray services. You say that the service was medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available. 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 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 the portable x-ray services (R0070, 71045, Q0092) provided on January 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 2, 2020 to January 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the medical services provided out of network. You say that the medical records provided support that payment should be made based on the medical necessity of the services in dispute. The Plan denied your request. The Plan says there is no valid referral for the out of network services in dispute.
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 medical services provided on January 2, 2020 to January 15, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from September 8, 2019 to September 30, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a required Q code to indicate where home health services were provided was not reported along with the first billed home health service.
The Plan must follow Medicare rules. Medicare rules say that home health services must be billed correctly. The required Q code to indicate where the services were provided was not reported on the claim. 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 for home health services provided to the enrollee from September 8, 2019 to September 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services provided on December 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the surgical pathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. The requested provider in this case was not Medicare-certified during the date of service 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 surgical pathology services provided on December 9, 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 partial upper denture (D5210) provided on January 20, 2020.
You asked the Plan to pay for the dental item. You say that the partial denture should be covered. The Plan denied your request. The Plan says dentures are covered 1 time in a 5 year period. The Plan also says that the benefit for dentures has 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 and the partial denture is listed as a covered service, the benefit limit for partial dentures has been exceeded. The record shows that the Plan paid for the partial upper denture that you received on February 5, 2018. Therefore, we decided that the Plan does not have to pay for the partial upper denture (D5210) provided on January 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on February 18, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found based on the medical records provided the UTI Panel performed by the Provider (collected on 02/18/2020) does not meet criteria as medically reasonable and 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 services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 4, 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 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 for the drug testing rendered on November 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the diabetic supplies provided on January 15,
2020.
You asked the Plan to reimburse you for the diabetic supplies. You say that you have been ordering your
diabetic supplies from a network provider. You say you were looking for a more economical supplier so you
ordered the supplies online. The Plan denied your request. The Plan says you must receive care from innetwork
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.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare
program.
We looked at the file and Medicare rules. You purchased the diabetic supplies from an online company that is
not a provider or a supplier that is enrolled in the Medicare program. Therefore, we decided that the Plan does
not have to reimburse you for the diabetic supplies provided on January 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral medications that you purchased while out of the country on November 12, 2019. You asked the Plan to reimburse you for the oral medications. You say that you were diagnosed with pneumonia while you were in Israel. You say that you purchased these medications while you were there. You say that it is your understand that you have prescription drug coverage and that you have coverage for emergencies regardless of your location. The Plan denied your request. The Plan says there is limited coverage for emergency care outside of the United States. The Plan also says that prescription drugs purchased outside of the United States are not covered under any condition. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to reimburse you for the oral medications that you purchased while out of the country on November 12, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on October 3, 2019.
You asked the Plan to waive the copayment for the ER visit. You say that he was admitted on two dates for the
same reason. You say that he shouldn't have to pay for a return trip to the hospital. The Plan denied your
request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $120 copayment for Medicare-covered emergency room visits.
The enrollee has been asked to pay a $120 copayment for the ER visit. the ER visit falls within the "Emergency
Care" benefit category. The records show that this was a separate visit to the ER. 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 the ER visit provided on October 3, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy visits (97110).
You asked the Plan to pre-approve physical therapy visits. You say that the services are necessary. The Plan
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has
not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 physical therapy visits. Our reviewer
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the
enrollee's condition. Our physician reviewer found the requested additional therapy is generally not accepted as
specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy with
persistent significant deficits despite 25 sessions and is versed in a home exercise program. The enrollee no
longer requires the skills of a professional therapist. She does not need the unique skills of a professional
therapist to safely and effectively provide treatment. Services do not only need to be safely and effectively
performed by a therapist, or under the supervision of a therapist. The requested services are not part of a
maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required
to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow
further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve physical therapy visits (97110).