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

We decided that the Plan does not have to waive the copayment for the laboratory work on March 2, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that the laboratory services were
ordered for your annual physical. You say you have a $0 copayment for an annual physical. 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 $10
copayment for Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR
testing (anti-coagulant testing). You will only pay one copayment per day even if multiple lab tests are
performed.
You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within
"Outpatient diagnostic tests and therapeutic supplies and services" benefit category. Please note, laboratory
services are not included in an annual physical exam.
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 laboratory work provided on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lysol spray (E1399).
You asked the Plan to pre-approve Lysol spray. You say that you feel that this should be covered because you tested positive for Covid19 and you need to disinfect your house to prevent the spread of the virus to others. The Plan denied your request. The Plan says this item is not covered.
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 Lysol spray (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that you would like to appeal the Plan's denial of the elevator lift equipment. You say that you need the lift because you cannot climb your stairs and the requested equipment would make it more comfortable for you. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CYP gene panel provided on January 22, 2020.
You asked the Plan to pay for the CYP gene panel. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that CYP gene panels are not covered. We looked at the file and Medicare rules. In this case, the file shows you billed for a CYP gene panel. These panels should be billed with a single code - CPT 81479. CYP gene panels that test for multiple CYP genes are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the CYP gene panel have not been met. Therefore, we decided that the Plan does not have to pay for the CYP gene panel provided on January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve You asked the Plan to pre-approve the denture. You say that the records should support the necessity of the service in dispute.The Plan denied your request. The Plan says this service is not covered under the plan benefits.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 lower partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve consultation visits. You say that you have communicated with the requested provider who is willing to proceed with a biopsy, and once a diagnosis is established care can proceed. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated within the Plan 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. 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-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Myocardial Perfusion Imaging (78452, A9502, 93017) provided on February 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the Myocardial Perfusion Imaging. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized or emergent. 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 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 Myocardial Perfusion Imaging (78452, A9502, 93017) provided on February 14, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 25, 2018 through October 27, 2018.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from October 25, 2018 through October 27, 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an Emergency Room Visit and Ambulance Transport provided October 27, 2019.
You asked the Plan to waive the copayments for the Emergency Room visit and the Ambulance Transport. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct copayments were 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). Your contract with the Plan clearly says that you must pay a $90 copayment for Emergency Care and a $200 copayment for Ambulance Services. You have been asked to pay a $90 copayment and a $200 copayment for the Emergency Room visit and the Ambulance Transport. The Emergency Room visit and the Ambulance Transport falls within the Emergency Care and Ambulance Services benefit categories. 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 an Emergency Room Visit and Ambulance Transport provided October 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for unspecified periodontal procedure (D4999) and to waive the
coinsurance for periodontal scaling and root planing (D4341) provided March 11, 2020.
You asked the Plan to pay for the dental services. You say that you only wanted your regular free yearly
cleaning. They should have talked to your first. This was their mistake and you should not have to pay for this.
The Plan denied your request. The Plan says D4999 is not covered under the plan benefits. The correct
coinsurance was applied to D4341 per the plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing
information (such as copayments, deductibles and coinsurance). For that reason, the Plan's coverage rules
apply in this case. Services not listed under the list of covered dental procedures are not covered by the plan.
The plan contract says that you must pay 50% coinsurance for this service.
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 pay for
unspecified periodontal procedure (D4999) and to waive the coinsurance for periodontal scaling and root
planing (D4341) provided March 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on March 10, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that your doctor wanted this done prior to surgery. You say that you shouldn't have to pay. 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 a $60 copayment for Medicare-covered x-rays and ultrasounds. You have been asked to pay $35.77, which is less than the standard $60 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. There is no provision in the contract which indicates a copayment would be waived if performed as a pre-operative service. 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 x-ray provided on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deluxe frames and scratch resistant lenses to be purchased from an out of network vendor.
You asked the Plan to pre-approve the frames and lenses. You say that you do not like the frames offered by the network provider and you want to go to an out of network vendor for more fashionable eyeglass frames with scratch resistant lenses. The Plan denied your request. The Plan says there is no medical or clinical reason to suggest that the enrollee would need scratch resistant lenses or different frames.
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status. 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 frames and lenses. Our reviewer says that Our physician reviewer found 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 frames and lenses have not been met. Therefore, we decided that the Plan does not have to pre-approve deluxe frames and scratch resistant lenses to be purchased from an out of network vendor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup provided on March 19, 2020.
You asked the Plan to pay for the core buildup. You say that this should be covered. The Plan denied your
request. The Plan says that this is not a covered service.
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 pay for the core
buildup provided on March 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to the nursing home
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to the nursing home (R0075). You say that the Plan should pay this claim. The Plan denied your request. The Plan says in this place of service the claim is not separately reimbursable.
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 the transportation and set up costs are subject to consolidated billing. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel to the nursing home (R0075) have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to the nursing home provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient services provided on March 4, 2020 through March 11, 2020.
You asked the Plan to waive the deductible for the outpatient services. You say that you would like reconsideration because you paid your copayments at the time of service. The Plan denied your request. The Plan says the claim was originally processed with the correct member responsibility.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,300 deductible before the Plan will pay their share for covered services.. The items or services you asked the Plan to waive the deductible for are subject to your deductible amount. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,300 deductible before the Plan will pay their share for covered services. The record indicates that you had not met your deductible amount as of the date of service. This cost sharing is a contractual obligation that had not been met at the time the outpatient services was received on March 4, 2020 to March 11, 2020. Therefore, we decided that the Plan does not have to waive the deductible for outpatient services provided on March 4, 2020 through March 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the Plan should review their denial and
reprocess the claim for payment. The Plan denied your request. The Plan says these services are not a covered
benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on January 26, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on June 19, 2019.You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation does not include evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on June 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 11, 2019.
You asked the Plan to pay for the laboratory 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.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, 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. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 25, 2019.You asked the Plan to pay for the physician's services. You say that this provider is your family physician and these services should be covered as they are preventive. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown on tooth 11 (D2740).
You asked the Plan to pay for the crown. You say that the records should support the necessity of the service.
The Plan denied your request. The Plan says the documentation provided does not support the criteria for
approval for the requested crown.
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. The Plan covers the crown
when the services are medically necessary and reasonable.
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 crown. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found in this case as there is more than sufficient strength remaining in the tooth, a crown is not
indicated. Plan criteria for crowns also state that "Permanent anterior teeth must have pathologic destruction to
the tooth by caries or trauma, and must involve four or more surfaces and at least 50% of the incisal edge. "
Again, this tooth has about 80% remaining structure and is not in need of a crown by any standard. There is no
medical necessity for a crown on tooth #11.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have
to pay for a crown on tooth 11 (D2740).