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

We decided that the Plan does not have to waive the copayment applied to an emergency room visit billed for date of service February 2, 2020.
You asked the Plan to waive the copayment applied to the emergency room visit. You say that you went to the emergency room and they did not treat you. You say that the emergency room did not do anything for you and you were not given a drug. You say that the emergency room was unable to treat you and referred you to another hospital for care. The Plan denied your request. The Plan says the copayment was appropriately applied to the services in dispute.
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. You have been asked to pay a $90 copayment for the emergency room visit. The medical records support that care was provided in the emergency room on the date of service in dispute. The emergency room visit falls within the Emergency 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 applied to an emergency room visit billed for date of service February 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on May 16, 2019 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you confirmed with the dental office manager that the treating provider is in network. You also say that you have gone to this provider for many years. The Plan denied your request. The Plan says the services were rendered by a non-contracted provider. The Plan also says that your benefit plan does not offer any OON 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on May 16, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician services.
You asked the Plan to pre-approve the physician services. The Plan denied your request. The Plan says you must receive care from a network provider unless it is an emergency or if the care cannot be provided by a 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Tetanus immunization (90714) provided on March 10, 2020.
You asked the Plan to pay for the Tetanus immunization. You say that you would like reconsideration as you should not be liable for this service. The Plan denied your request. The Plan says the benefits for this charge must be determined by filing through your pharmacy network.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus immunization. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tetanus immunization. Therefore, we decided that the Plan does not have to pay for a Tetanus immunization (90714) provided on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January 17, 2020.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says documentation submitted did not indicate the provider discussed the need for the billed supply code, therefore 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 looked at the file and Medicare rules. The medical record does not mention or support medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the knee orthosis (L1833) and suspension sleeve (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 7, 2020.You asked the Plan to pay for home health services. You say that you would like reconsideration as this claim was billed correctly.The Plan denied your request. The Plan says the HIPPS codes submitted are invalid.The Plan must follow Medicare rules.The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this bill has been claimed with an invalid HIPPS code. Per CMS, the HIPPS code included on this claim was retired on December 31, 2019.Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on October, 16, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician services. 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 forphysician services provided on October, 16, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided on December 3, 2019.You asked the Plan to pay fordrug tests. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support the services billed.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 valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to payfordrug testing provided on December 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 13, 2020.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition form. 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 valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.
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 valid 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 January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 3, 2020 by an out of network (OON) provider.You asked the Plan to pay forlaboratory tests. You say that these tests were medically necessary.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring provider is also out-of-network with the Plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has topay 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 medical services provided on February 3, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on January 17, 2020.You asked the Plan to waive the copayment for the colonoscopy. You say that you were informed this would be preventive. You say that you were informed you wouldn't be charged.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 $250 copayment for ambulatory surgical center and outpatient hospital visits.You have been asked to pay a $250 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 records show that polyps were removed,which 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 copayment for the colonoscopy provided on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you would like to appeal the Plan's denial of the requested shower bench because you need it but you cannot afford it. You say that you have previously fallen in the bathtub and onto the floor. You stated that you have been in the hospital for your kidney problems and you use an IV at home. You say that you need the shower bench to sit and bathe when you feel dizzy. You stated that there are medical records showing evidence that you need the shower bench to bathe. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair 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 shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 14, 2020.
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 procedure codes 80157, 80177, 80201, 80159 and 80173 are not supported.
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 80157 is assay of arbamazepine; free. The definition of code 80177 is levetiracetam drug screen. The definition of code 80201 is assay of topiramate. The definition of code 80159 is assay of clozapine. The definition of code 80173 is assay of haloperidol. We find that CPT codes 80157, 80177, 80201, 80159 and 80173 are not supported in the medical record. Specifically, there is no documentation that carbamazepine; free was performed on the specimens to support code 80157. There is no documentation of levetiracetam testing on the specimens to support code 80177. There is no documentation of topiramate testing on the specimens to support code 80201. There is no documentation of clozapine testing to support code 80159. There is no documentation of haloperidol testing to support code 80173. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 14, 2020
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Over-the-counter (OTC) items (including masks, tape, and alcohol pads).You asked the Plan to pre-approve the over-the-counter items. You say that the plan provider is out of stock of the desired items.The Plan denied your request. The Plan says that the items must be purchased from its provider, Convey.The Plan must follow Medicare rules. Medicare rules say that a plan must ensure that the retail outlets through which enrollees may obtain the covered OTC items are distributed within the service area to ensure that the benefit is uniformly offered and that all enrollees have access to the benefit. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested OTC items have been met. Specifically, the Plan has not ensured that the OTC benefit is accessible to you. The requested OTC items are not in stock with the Plan vendor and the Plan has made no alternative providers available for you to get the covered items. You therefore do not have access to the OTC benefit as required by Medicare rules. The Plan must arrange for access through a vendor that is not out of stock.Therefore, we decided that the Plan has to pre-approve Over-the-counter (OTC) items (including masks, tape, and alcohol pads).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 reimburse you for the eyewear provided on March 10, 2020 by an out of network provider. You asked the Plan to reimburse you for the eyewear. You say that you sought out a less expensive lens and frame so you should not be denied. The Plan denied your request. The Plan says there is no out-of-network coverage for lenses and frames. 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 reimburse you 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 at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to reimburse you for these items. Therefore, we decided that the Plan does not have to reimburse you for the eyewear provided on March 10, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eyewear provided on December 4, 2019.You asked the Plan to pay forthe eyewear. The Plan denied your request. The Plan says that you must use a plan optical facility for purchases of eyewear.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 plan optical facility.We looked at the file and the Plan's rules. The file indicates you did not purchase the eyewear from a plan optical facility.Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met.Therefore, we decided that the Plan does not have to pay forthe eyewear provided on December 4, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on December 2, 2019 by an out of network (OON) provider.You asked the Plan to pay for therapeutic exercises. 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. The Plan says that the member's primary care physician did not refer these services. The Plan says that the referring provider is 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 nota 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 therapeutic exercises provided on December 2, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on March 30, 2020.You asked the Plan to pay for the problem focused limited oral evaluation. You say that this procedure was an emergency. You also say that your provider advised that you would have no out of pocket cost for the service.The Plan denied your request. The Plan says this procedure is covered once every 6 months.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, oral exams are limited to 1 every 6 months. The record shows that you received a periodic oral evaluation on December 17, 2019, and your exams benefit had been exhausted for the 6 month time period.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation provided on March 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gastroenterology panel rendered on December 16, 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 were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a gastroenterology panel is covered when
specific criteria are met.
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 these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee has a past medical history of
a benign neoplasm of the colon, gastroesophageal reflux disease, gastritis and diverticulosis and was evaluated
with an infectious agent detection panel. The records do not support that the Medicare criteria for these services
were met; therefore, the services were 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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for the gastroenterology panel rendered on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone graft (D7953) provided January 9, 2020.
You asked the Plan to pay for the bone graft. You say that the services were medically necessary. The Plan denied your request. The Plan says the bone graft 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 a bone graft (D7953) provided January 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora mammography (77067 and 77063) provided on January 24, 2020.You asked the Plan to pay forthe mammography. You say that you would like reconsideration because the member received multiple services on the same date of service.The Plan denied your request. The Plan says the record supports one unit of 77067 and 77063 which were already approved and paid.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the mammography have not been met. Specifically, the record indicates that one unit of these services was rendered. These services have already been approved and paid and there is no further documentation to support more than one unit.Therefore, we decided that the Plan does not have to pay fora mammography (77067 and 77063) provided on January 24, 2020.