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

We decided that the Plan does not have to waive the copayment for pulse oximetry provided on November 7, 2019.You asked the Plan to waive the copayment for pulse oximetry. You say that the enrollee did not receive the services.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $30copayment for outpatient diagnostic tests provided by a specialist. The medical records show that the enrollee received pulse oximetry on November 7, 2019. Therefore, the enrollee is responsible to pay the allowed amount of $23.51, which is less than the $30 copayment. The enrollee has been asked to pay $23.51for pulse oximetry. Pulse oximetry falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 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 pulse oximetry provided on November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on October 28, 2019.
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says that the billed supply code cannot be verified.
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 orthosis. Our reviewer says that the orthosis is not considered medically reasonable and necessary in this case. The office visit dated 8/27/19 documents Lumbar post-laminectomy syndrome, Spinal cord stimulator status, and Back pain on the Active Problem List. However, there is no documentation of current back pain and there is no documented physical examination of the back. A listed indication for a lumbar sacral orthosis is not documented. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for the orthosis.
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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four (TOF) testing (CPT 95999) provided on September 9, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.The Plan must follow Medicare rules. Medicare rules say that all services which are integral to accomplishing a procedure are considered a component part of a comprehensive code.IONM services cannot be performed without TOF monitoring. This means that TOF testing is considered integral to the performance of IONM services. As such, this component of the procedure is included in payment for the overall IONM monitoring service which was already paid. No separate payment can be made for this part of the service. 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 the train of four (TOF) testing (CPT 95999) provided on September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on October 25, 2019.You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.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. The medical records do not mention a need for braces until after the date of service. Based on this information, we decided that Medicare rules for coverage of the knee orthoses (L1833) and suspension sleeves (L2397) have not been met.Therefore, we decided that the Plan does not have to pay for the knee orthoses (L1833) and suspension sleeves provided on October 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on August 15, 2019.
You asked the Plan to pay for drug test. You say that you are appealing with records. The Plan denied your
request. The Plan says the denial of payment for this service is correct, because the documentation submitted
does not include a physician order or requisition that supports the specific test billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or
clear intent to order the specific lab service billed on this claim. Based on this information, we decided that
Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have
to pay for drug testing provided on August 15, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit on June 13 and 14, 2019. 
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $100 copayment for Emergency Room Visits. The enrollee has been asked to pay a $100 copayment for the emergency room visit. 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 an emergency room visit on June 13 and 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan provided on July 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a duplex scan. You say that the member is in a skilled nursing facility; therefore, the doctor is not responsible to get authorization. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
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 a duplex scan provided on July 20, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on May 4, 2017.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
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 the services was not filed until January 10, 2019. 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 services provided on May 4, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an over-bed table.
You asked the Plan to pre-approve the table. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an over-bed table.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473).You asked the Plan to pre-approve the removal of torus mandibularis. You say that when you chew your jaw becomes inflamed and you cannot move it without being in pain. You also say that this interferes with you eating regular foods.The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances.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 pre-approve the removal of torus mandibularis (D7473).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the bone growth stimulator provided on November 7, 2019.
You asked the Plan to waive the coinsurance for the bone growth stimulator. You say that you cannot afford this copayment. You say you did not ask for the device and feel like you should not be liable. 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 20% coinsurance per Medicare-covered item. You have been asked to pay $895.94 which is 20% of the allowed amount for the bone growth stimulator. The allowed amount is $4,479.68. ($4,479.68 x 20% = $895.94). The bone growth stimulator falls within the "Durable medical equipment (DME) and related 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 bone growth stimulator provided on November 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 22, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 payfor these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on October 22, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.
You asked the Plan to pre-approve Hyalgan. You say that the requested Hyalgan is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Euflexxa and Gel-One first.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Hyalgan. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of Other chondrocalcinosis, left knee. The Plan requires a trial of drugs Euflexxa and Gel-One first before they will approve the requested drug, Hyalgan. The documentation does not show the enrollee has tried and failed the preferred drugs. The documentation does not support that Euflexxa and Gel-One would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient physical therapy visits.

You asked the Plan to pre-approve physical therapy. You say that continued physical therapy is vital to prevent another procedure, and the enrollee is not able to apply the appropriate stresses on his own at this time. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because these services are not medically necessary.

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. 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 this therapy is generally accepted as a specific and effective therapy for reducing pain, restoring function, and educating regarding a home-exercise program for transition towards a home program. There is no indication that residual deficits could not be address with a home exercise program, therefore this request 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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided on October 26, 2019.
You asked the Plan to pay for a pneumatic compression device (E0676). You say that the device was used postoperative to prevent DVT & PE. The Plan denied your request. The Plan says the equipment was used to prevent a thromboembolic event.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 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 provided on October 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from September 4, 2019 to October 15, 2019. You asked the Plan to waive the copayments for the physical therapy visits. You say that you were told you could have physical therapy at home or the hospital with a $0 copayment. You say if you had known the copayments were $40 a session you would have done the therapy at home. 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 $40 copayment for each in-network Medicare-covered physical therapy and speech-language therapy visits. You have been asked to pay a $40 copayment for each of the physical therapy visits. The physical therapy visits 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 the physical therapy visits provided from September 4, 2019 to October 15, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the lenses provided on November 15, 2019.You asked the Plan to pay forthe lenses. You say that you want reimbursement for the vision services.The Plan denied your request. The Plan says that that the provider must submit the claim.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 received from a network provider.We looked at the file and the Plan's rules. The file indicates you received the lenses from a network provider. Based on this information, we decided that the Plan's rules for coverage of the lenses have been met.Therefore, we decided that the Plan has to pay for the lenses up to the plan maximum of $100 provided on November 15, 2019. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 7, 2019 and June 28, 2019.
You asked the Plan to pay for physician services provided to the enrollee. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 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 out of network physician services provided to the enrollee from June 7, 2019 and June 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthoses, heel stabilizers, the lumbar-sacral orthosis, and the knee orthoses and suspension sleeves provided on August 19, 2019. You asked the Plan to pay for the ankle foot orthoses (L1971), heel stabilizers (L3170), the lumbar-sacral orthosis (L0650), and the knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says you did not submit a valid physician order, Proof of Delivery, or a Delivery Ticket. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. There is no physician order or Proof of Delivery I the case file. Therefore, we decided that the Plan does not have to pay for the ankle foot orthoses, heel stabilizers, the lumbar-sacral orthosis, and the knee orthoses and suspension sleeves provided on August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not have to pre-approvedental services (D6010, D6050, D6059) for the enrollee.You asked the Planto pre-approvethe services. You say that the enrollee has a complex medical history and will benefit with dental treatment.The Plandenied your request. The Plansaysthis is not a covered benefit.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 (D6010, D6050, D6059) are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvedental services (D6010, D6050, D6059) for the enrollee.