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

We decided that the Plan does not have to pay forthe laboratory services provided on January 15, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese OON services. You say that you would like the plan to reconsider their denialThe Plan denied your request. The Plan says the services rendered are not a covered benefit.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 forthe laboratory services provided on January 15, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on March 16, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that you were told that there would only be a $35 copayment for the CT scan. 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 each in-network Medicare-covered service for diagnostic imaging (CT scan, MRI/MRA, myocardial nuclear perfusion imaging and PET scans). You have been asked to pay a $150 copayment for the CT scan. The CT scan 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 forthe CT scan provided on March 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional transportation is necessary for you to be able to get to your medical appointments. The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria has 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 12 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 (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on September 16, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for an outpatient visit. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 an outpatient visit provided on September 16,
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Osteogenesis bone growth stimulator (E0747).You asked the Plan to pre-approve the bone growth stimulator. You say that you are requesting reconsideration of the denial of the bone stimulator to augment her fusion.The Plan denied your request. The Plan says the bone growth stimulator is not medically necessary because the coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 bone growth stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for bone stimulator not met. Not enough time has passed to establish the diagnosis of nonunion.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 bone growth stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approve Osteogenesis bone growth stimulator (E0747).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 14 extractions (D7140) provided on December 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe dental services. You say that the extractions are to prepare the enrollee's jaw for radiation treatment.  The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says that the enrollee was referred by another non-network provider. The Plan also says the services were not urgent or emergent in nature.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 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 doesnot have to pay forthe 14 extractions (D7140) provided on December 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 chiropractic visits provided from November 13, 2019 to November 27, 2019.
You asked the Plan to pay for chiropractic services. You say that you are in constant severe pain but are allergic to the medications that pain management providers offer, so the best solution for you has been chiropractic and acupuncture treatments. The Plan denied your request. The Plan says the denial of payment for these services is correct, because supplemental pain management services beyond 24 visits per year is not covered by the Plan.
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 Plan covers chiropractic services beyond Medicare's coverage for up to 24 visits per year. The records show that the service at issue is not manual manipulation of the spine. In addition, the Plan's supplemental benefits for pain management, including chiropractic services, was exhausted for 2019. Therefore, we decided that the Plan does not have to pay for chiropractic visits provided from November 13, 2019 to November 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveComputed Tomography (CT) scans of the chest, abdomen, and pelvis.You asked the Plan to pre-approveCT scans. You say that the enrollee is currently on chemotherapy treatment and the provider needs a repeat CT to check for any signs of disease progression.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because more information would be needed to show why these CT scans are requested before the 6-week interval for testing.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve CT scans. Our reviewer says that the enrollee does not meet the Medicare criteria for CT scans. Our physician reviewer found the enrollee's last scan was on May 15, 2020 and showed stable disease. The standardof care is a CT scan every 2 to 3 cycles to assess response to treatment. This enrollee is not yet due for another CT scan. Therefore, the requested CT scans are not medically reasonable and 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 CT scans have not been met.Therefore, we decided that the Plan does not have to pre-approveComputed Tomography (CT) scans of the chest, abdomen, and pelvis.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 2, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to
be performed.
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 a valid physician order or lab
requisition stating exactly which testing was to 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 for the drug testing services provided on January 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9375) provided on January 8, 2020 through January 11, 2020.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code S9375 has a status code of I which is invalid for Medicare purposes.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 code S9375 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9375 has a status code of I. This means that CPT code S9375 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9375) provided on January 8, 2020 through January 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 4, 2020.
You asked the Plan to pay for the laboratory 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 laboratory 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 laboratory services provided on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery backup for a CPAP machine (E1399).
You asked the Plan to pre-approve the battery. You say that the battery is medically necessary. The Plan denied your request. The Plan says batteries are not a covered item.
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 a battery backup for a CPAP machine (E1399).
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to hold you harmless for physical therapy services provided on April 13, 2018 through April 23, 2018.You asked the Plan to hold you harmless for the physical therapy services. You say that you would like reconsideration because you were not informed that pre-authorization was needed.The Plan denied your request. The Plan says that these services were denied due to no authorization and no medical records.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were referred for the physical therapy services by a contract provider. The file does not show that the Plan provided notice that the physical therapy services would not be covered. Under Medicare rules, this means the physical therapy services is considered approved by the Plan.Therefore, we decided that the Plan has to hold you harmless for physical therapy services provided on April 13, 2018 through April 23, 2018.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves, per 100.You asked the Plan to pre-approve non-sterile gloves. You say that you have no personal protective equipment and you would like the gloves for when you leave your home to protect you from exposure to Covid-19.The Plan denied your request. The Plan says this item 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 non-sterile gloves, per 100.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown provided on December 18, 2019.
You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown. You say that you have previously seen this provider and the Plan paid for the services. You also say that it is unfair of the Plan to place restrictions on your plan. The Plan denied your request. The Plan says these services are not a covered benefit when performed by a dentist who has affirmatively opted out of Medicare participation.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by this treating provider. This provider has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown provided on December 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopy and cystourethroscopy services provided on November 1, 2019.You asked the Plan to pay for the laparoscopy and cystourethroscopy 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 Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 52000. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid.Also,line 2 (CPT 57425, laparoscopy services) does not match the procedure code billed by the primary surgeon. Codes billed by the assistant surgeon should typically match codes billed by the primary surgeon.Lastly, the amount owed for code 58571 (laparoscopyservices) was applied towards the enrollee's deductible.Based upon this information, we find that Medicare coverage criteria for the laparoscopy services have not been met.Therefore, we decided that the Plan does not have to pay for the laparoscopy and cystourethroscopy services provided on November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 16, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that the doctor provided no service and you should not be responsible for the 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 $40 copayment per specialist visit. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were evaluated by the provider.
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 specialist office visit provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on October 30, 2019.You asked the Plan to waive the copayment for the urgent care visit. You say that you did not see a doctor and they did not do anything. You say that you are being overcharged.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). Your contract with the Plan clearly says that you must pay $45 for each Medicare-covered office visit to other providers for urgently needed services.You have been asked to pay a $45 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The records show that you were examined and advised to go to the emergency department. 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 urgent care visit provided on October 30, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided by on February 7, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that you do not feel you should have to pay the copayment because the colonoscopy was fully finished. 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 $100 copayment for each Medicare-covered ambulatory surgical center. You have been asked to pay a $100 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 the colonoscopy was completed with no complications. The medical record also shows polyps were removed which make the colonoscopy diagnostic in nature.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living services provided on January 20, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for assisted living services. You say that these services were provided in an assisted
living facility. You say that this is the primary care physician in the facility. The Plan denied your request. The
Plan says no prior authorization was obtained. The Plan says that there are in-network providers available for
these 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 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 assisted living services provided on January 20,
2020 by an out of network (OON) provider.