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

We decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) of the shoulder and knee for the enrollee.You asked the Plan to pre-approveeither of the MRI's requested. You say that the requested imaging is medically necessary for the enrollee.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 was correct in denying the request to pre-approve either of the MRI's requested. Our reviewer says that the Medicare criteria for an upper and lower extremity MRI are not met. Our physician reviewer found based on the documentation provided, there is no documentation of newor recent injury. Physical examination confirms pain with movement, but no evidence of joint laxityor instability or weakness. Plain radiographs were non-actionable. There is no documentation of a trial of conservative therapy (medication or physical therapy). While osteoarthritis is suspected, MRIs ordered for screeningor diagnostic assuranceare not covered.The documentation does not support that the requested MRIs are medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of either of the MRI's requested have not been met.Therefore, we decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) of the shoulder and knee for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCequa 0.09% solution.You asked the Plan to pre-approveCequa 0.09% solution. You say that the requested medication is necessary.The Plan denied your request. The Plan says you have a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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 pre-approveCequa 0.09% solution.Benefits for Cequa 0.09% solutionmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe colonoscopy with lesion removal provided on July 12, 2019 by the out of network provider.You asked the Plan to pay forthe surgical services. You say that  The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.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 referringprovider is not a network provider either. 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 colonoscopy with lesion removal provided on July 12, 2019 by the out of network provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from August 3, 2019 to August 10, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does
not have to pay for the home infusion therapy rendered to the enrollee from August 3, 2019 to August 10, 2019.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS emergency ambulance service (A0429) and ground
mileage (A0425) provided on September 7, 2019.
You asked the Plan to pay for the ambulance service. You say that the enrollee was not covered under hospice
on the date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for
payment of all Medicare covered services related or unrelated to the member's terminal condition until the first
day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the BLS emergency ambulance service (A0429) and ground
mileage (A0425) provided on September 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe second opinion for HPV testing to be provided by the out of network provider.You asked the Plan to pre-approvethe physician services. You say that you are not confident that the Plan provider can a provide an honest second opinion.The Plan denied your request. The Plan says you must receive care from in network providers.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 pre-approve 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe second opinion for HPV testing to be provided by the out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional services and supplies provided during ambulance transportation on July 17, 2019.
You asked the Plan to pay for the additional services. The Plan denied your request. The Plan says payment for services is included in the transportation fee.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. The file shows that you received disposable supplies, oxygen, and a wait charge during your ambulance transportation services. We looked at the file, and Medicare rules. These are all considered part of the general ambulance service and payment for them is included in the payment rate for the transport. 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 pay for the additional services and supplies provided during ambulance transportation on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on January 7, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed.
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 99239 is hospital discharge day management; more than 30 minutes.
We find that CPT code 99239 is not supported in the record. Specifically, the record does not indicate that more than 30 minutes of hospital discharge day management services were rendered. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on January 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial nursing facility care, and debridement of muscle or fascia provided on November 16, 2018 by the out of network provider.You asked the Plan to pay forthe wound care services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's physician did not refer them for the services. The Plan also says the services were not urgent or emergent.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 referring provider is not a network provider either. 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 initial nursing facility care, and debridement of muscle or fascia provided on November 16, 2018 by the out of network provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot orthotics received on July 30, 2019.
You asked the Plan to pay for foot orthotics. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for the foot orthotics received on July 30, 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 August 20, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were not told you would be billed for the x-ray and the office visit separately. 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 $50 copayment per visit for a specialist office visit. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows this provider only billed for the specialist office visit.
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 on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin-based composite provided on July 25, 2019.You asked the Plan to pay forthe resin-based composite. You say that the provider who rendered the resin-based composite fixed your tooth correctly. You also say that you would like the Plan to get the money back from Federal Way and pay this provider's office.The Plan denied your request. The Plan says the services are covered benefits, but you haveexceeded the limits set in the subscriber agreement. The Plan also says that after the annual maximum of $2,000 is exhausted, any remaining charges are your responsibility.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 Plan offers a $2,000 annual dental benefit maximum. The Record shows that you met the annual deductible benefit on February 19, 2019 and your annual deductible benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe resin-based composite provided on July 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from July 31, 2019 to August 3, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you would like to have the second charge of $425 waived since the second admission to the second hospital was for the same treatment. 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 $425 copayment per admission for inpatient hospital care. You have been asked to pay a $425 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from July 31, 2019 to August 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forvision services provided by "the provider" on April 10, 2019.You asked the Plan to waive the copayment forthe services. You say that this should be paid for.The Plan denied your request. The Plan says you are responsible for the coinsurance.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% coinsurance for out-of-network vision care. You have been asked to pay 45% coinsurance for the services. The services fall within the out-of-network vision carebenefit 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 doesnot have to waive the copayment forvision services provided by "the provider" on April 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on August 27, 2019 through September 3, 2019.
You asked the Plan to pay for the home infusion therapy. You say that S9328 is a valid code per CMS. The Plan denied your request. The Plan says S9328 has a status code of I which is not valid 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 S9328 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, S9328 has a status code of I. This means that S9328 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 (S9328) provided on August 27, 2019 through September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foroncology (prostate) geneexpression profile testing provided by "the provider" on June 17, 2019.You asked the Plan to pay forgenetic test. You say that this test was ordered by the treating physician because it was medically necessary.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not considered medically necessary and is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that oncology gene expression profile testing with procedure code 0005U was not covered by Medicare for date of service June 17, 2019. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic test have not been met.Therefore,we decided that the Plan does not have to pay foroncology (prostate) gene expression profile testing provided by "the provider" on June 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant surgery services provided on March 5, 2019.You asked the Plan to pay forthe assistant surgeryservices. 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 a covered benefit.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay forthe assistant surgery services provided onMarch 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the eye injections provided from March 5,
2019 to August 28, 2019.
You asked the Plan to waive the copayments for the eye injections. You say that the services you received is
not done in a surgical setting but done in a treatment room. You say you cannot afford the additional fee of
$120 per visit. 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 $120
copayment for each Medicare-covered outpatient surgery in an ambulatory surgical center or hospital
outpatient facility.
You have been asked to pay a $120 copayment for each of the eye injections. The eye injections fall within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The record shows the eye injection is considered a surgical procedure.
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 eye injections provided from March 5, 2019 to August
28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services (G0299) provided on May 19, 2019 through May 27, 2019.
You asked the Plan to pay for the skilled nursing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was billed without first submitting the required HHA reports and the provider has nit net criteria necessary for home health service.
The Plan must follow Medicare rules. Medicare rules say that institutional providers, including home health agencies, use one of two institutional claim formats to bill Original Medicare. We looked at the file and Medicare rules. In this case, the provider is an institutional provider and did not bill on an 837 institutional claim or on a UB-04. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing services (G0299) provided on May 19, 2019 through May 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance ride provided on July 1, 2019.You asked the Plan to waive the copayment forthe ambulance ride. You say that the out-of-network copayment should not apply due to an emergency while in Florida. 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 $250 copayment for each in-or out-of-network Medicare-covered one-way trip via ground ambulance. You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 forthe ambulance ride provided on July 1, 2019