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

We decided that the Plan does not have to pay for the medical services provided on January 31, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the rendering 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 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 the medical services provided on January 31, 2020 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 crown provided on February 26, 2020.
You asked the Plan to pay for the crown. You say that you received a pre-approval for this service in December 2019. You also say that you did not receive any information from the Plan regarding any changes to your plan coverage. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown provided on February 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve Dupixent. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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-approve Dupixent.
Benefits for Dupixent 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Freestyle Libre 14 day system for the enrollee.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your
request. The Plan says that Medicare guidelines are statutorily not met for coverage of the requested continuous
glucose monitor.
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically
necessary. The rules say that continuous glucose monitors are covered when they are therapeutic and needed to
treat diabetes.
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 system. Our reviewer says that the
requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has uncontrolled diabetes mellitus, and is a great risk for cardiovascular symptoms.
This is necessary to accurately guide therapy. Better glycemic control is limited by the inability of the enrollee
to test more frequently. Risks of low blood sugar are life-threatening.
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 system have been met. Therefore, we decided that the Plan has to preapprove
a Freestyle Libre 14 day system for the enrollee.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Euflexxa injection provided on March 9, 2020, March 16, 2020 and March 24, 2020.
You asked the Plan to waive the coinsurance for the Euflexxa injection. You say that the doctor's office told you the injection would be covered. You say that you already paid them once and now they want more. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a total of $173.61 for the Euflexxa injections.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
March 9, 2020
Euflexxa Injection
$289.38
20%
$57.87
March 16, 2020
Euflexxa Injection
$289.38
20%
$57.87
March 24, 2020
Euflexxa Injection
$289.38
20%
$57.87
TOTAL:
$173.61
The Euflexxa injections fall within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Euflexxa injection provided on March 9, 2020, March 16, 2020 and March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit and lesion removal provided on January 13, 2020.
You asked the Plan to waive the deductible for the office visit and lesion removal. You say that the Plan failed to mention the deductible. You say that you should be reimbursed. The Plan denied your request. The Plan says the deductible applied correctly.
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 your deductible is $300. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Physician services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $300 deductible applies to physician services. This cost sharing is a contractual obligation that had not been met at the time the office visit and lesion removal were received on January 13, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the office visit and lesion removal provided on January 13, 2020.
Your complaint about being treated unfairly and misled by the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 29, 2019.
You asked the Plan to pay for the laboratory services. 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 the laboratory services are not supported in the medical record. Specifically, the submitted documentation did not contain laboratory results from the billing provider. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on January 29, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 to the enrollee on January 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on August 9, 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 procedure code J0280 is 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 J0280 is injection, aminophyllin, up to 250 mg. We find that CPT code J0280 is not supported in the medical record. Specifically, the documentation does not support the two units billed of this code. 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 injection rendered on August 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory tests provided on January 8, 2020.
You asked the Plan to waive the copayment for the laboratory tests. You say that it should be a $0 copayment. 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 $10 per day, per in-network provider, for Medicare-covered lab services. You have been asked to pay a $10 copayment for the laboratory tests. The laboratory tests fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate 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 laboratory tests provided on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on January 16, 2020.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on August 15, 2019.
You asked the Plan to pay for the hearing aids. You say that The Plan denied your request. The Plan says that the claim denied correctly.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when you select a device from the list available through Plan participating hearing aid supplier. We looked at the file and the Plan's rules. The file indicates you did not get hearing aids from a participating hearing aid supplier. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on August 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy provided on August 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a colonoscopy. You say that you would like this claim reprocessed ad approved for payment. You say that these services were referred. The Plan denied your request. The Plan says there is no referral on file 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 a colonoscopy provided on August 23, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ER visits provided on February 1, 2020.
You asked the Plan to waive the copayments for ER visits. You say that you feel that you should not owe a second copayment because it was not your fault that you had to be transferred to another facility. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for emergency care. You had two ER visits on February 1, 2020. Therefore, you are responsible to pay a $65 copayment per each visit. The total amount you owe is: $65 (copayment) x 2 (ER visits) = $130. You have been asked to pay the total copayment amount of $130 for ER visits. ER visits fall 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 copayments for ER visits provided on February 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on October 14, 2019.
You asked the Plan to pay for the genetic 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 a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the genetic testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on October 14, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency care provided on February 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service was paid.
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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function". We find that CPT code 99285 is not supported in the medical record. Specifically, the records provided show that one unit of CPT 99285 was provided on February 8, 2020. The plan has already paid for one unit of CPT 99285 for this date of service. The records do not show that a second unit of CPT code 99285 was provided. 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 emergency care provided on February 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy services you received on August 30, 2019.
You asked the Plan to pay for the medical nutrition therapy services. You say that you were told that you did not have to pay for this. The Plan denied your request. The Plan says you do not meet the coverage criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. The records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for the medical nutrition therapy services you received on August 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee orthosis and suspension sleeve provided on November 12, 2018.
You asked the Plan to pre-approve the knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the enrollee received the same orthosis from a different provider on date of service November 14, 2018.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee had the same knee orthosis (L1851) and suspension sleeve (L2397) from a different provider at the time the orthoses was received from you. This knee orthosis (L1851) and suspension sleeve (L2397) serves the same purpose as the knee orthosis (L1851) and suspension sleeve (L2397) at issue. Based on the records provided, there is no indication the orthoses provided met Medicare coverage criteria for
replacement at the time of issue. Therefore, we decided that the Plan does not have to pre-approve the knee orthosis and suspension sleeve provided on November 12, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean outpatient visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approvean outpatient visit. You say that you would like approval for this office visit.The Plan denied your request. The Plan says there are multiple 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 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-approvean outpatient visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider at the in-network rate.You asked the Plan to pre-approvethe referral. You say that the requested chiropractor has been your doctor for the lastthirty years.The Plan denied your request. The Plan says the plan has 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 pre-approve care from out-of-network providers at the in-network rate 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 the referral at an in-network rate.Therefore, we decided that the Plan does not have to pre-approvea referral to an out-of-network provider at the in-network rate.