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

We decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on September 20, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 88334 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 88334 is pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), each additional site (List separately in addition to code for primary procedure).We find that CPT code 88334 is not supported in the medical record. Specifically, code 88334 is an add-on code that was not billed with a required primary procedure 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 forthe laboratory services rendered to the enrollee on September 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repair of an umbilical hernia (49585).
You asked the Plan to pre-approve repair of an umbilical hernia. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 repair of an umbilical hernia. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have an umbilical hernia and 3 lipomas which are not clearly described in size. There is no functional limitation from the lipomas and they appear cosmetic in nature at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of repair of an umbilical hernia have not been met. Therefore, we decided that the Plan does not have to pre-approve repair of an umbilical hernia (49585).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from May 14, 2019 to May 19, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were told that the MOOP for 2019 would be $3,400 and are unhappy with the misinformation. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee has been 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $350 copayment per day for days 1-5 for inpatient hospital care. The enrollee had an inpatient hospital stay from May 14, 2019 to May 19, 2019. The record shows that at the time services were rendered, the enrollee had only paid $4,244.60 toward the MOOP amount of $6,000. Therefore, the enrollee is responsible to pay a $350 copayment for days 1-5 (May 14, 2019 to May 18, 2019). $350 (copayment) x 5 (inpatient days) = $1,750.00. The enrollee has been asked to pay the total copayment amount of $1,750.00 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from May 14, 2019 to May 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on September 25, 2019.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The laboratory 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 laboratory testing provided on September 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 6, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says there was no physician order or proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order or proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forTherapeutic and Neuromuscular services provided by a chiropractor from May 6, 2019 to May 31, 2019.You asked the Plan to pay forTherapeutic and Neuromuscular services provided by a chiropractor. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says Therapeutic and Neuromuscular services provided by a chiropractor are not covered by Medicare.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forTherapeutic and Neuromuscular services provided by a chiropractor from May 6, 2019 to May 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided to the enrollee on May 3, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided to the enrollee on May 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing  on August 11, 2019.You asked the Plan to pay fordrug test. You say that this testing is a covered benefit and was ordered as part of the enrollee's treatment plan.The Plandenied your request. The Plan says the denial of payment for this service is correct, because no medical records have been submitted to show a specific reason for this testing.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 physician order or clear intent to order the specific test 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 on August 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and the coinsurance for an injection provided on October 4, 2019.
You asked the Plan to waive the copayment for a specialist office visit and an injection. You say that you do not feel like the amount you are being charged is fair. The Plan denied your request. The Plan says the correct copayment has been 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 $35 copayment and a 20% coinsurance for physician/practitioner services/specialist visit. You have been asked to pay a $35 copayment for a specialist office visit and a 20% coinsurance of the allowed amount for an injection. The total allowed amount for the injection is $25. The total amount you are being asked to pay for the injection is $5 ($25 x 20% = $5). The total amount you are being asked to pay is $40 ($35 + $5 = $40). A specialist office visit falls within the physician/practitioner services/specialist visit benefit category and an injection falls 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 copayment for a specialist office visit and the coinsurance for an injection provided on October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided
You asked the Plan to pre-approve the physician's services. You say that the enrollee has chronic refractory
cough and has had this cough for more than ten years and it has gradually gotten worse, to the point of not
being unable to walk or get out of bed. You say that the enrollee has undergone an extensive work-up including
a bronchoscopy on May 3, 2017, an allergy evaluation, as well as the enrollee has seen an otolaryngologist and
a gastro intestinal specialist. You say that the enrollee has tried and failed several medications. The Plan denied
your request. The Plan says the enrollee must receive care from in-network providers with the exception of
emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be
provided with an in-network provider, which requires prior authorization from 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 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. 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
physician's services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic services provided to the enrollee on July 19, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 diagnostic services provided to the enrollee on July 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the durable medical equipment to be provided by out of network provider
You asked the Plan to pre-approve an Omron blood pressure monitor, an Omron Transcutaneous electrical nerve stimulation device, a Thermapulse heating pad, and Futuro orthotics. You say that these brands of supplies are very important for your health and recovery from your pain. The Plan denied your request. The Plan says the supplier is not a contracted durable medical equipment supplier, some items can be bought with your Over-The-Counter Card, and some of the items are not covered by the Plan or Medicare.
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. The Plan has network providers available who can provide the some of the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve the durable medical equipment to be provided by out of network provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 13, 2019 to July 17, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee was not at a SNF receiving therapy from July 13, 2019 to July 17, 2019.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 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 skilled nursing services. Our reviewer says the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from July 13, 2019 to July 17, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy provided from June 25, 2019 through July 24, 2019.
You asked the Plan to waive the copayments for physical therapy. You say that this was ordered by the surgeon. You say that you were not informed there would be a copayment for each visit. The Plan denied your request. The Plan says the copayments 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 $15 for each Medicare-covered physical therapy visit. You have been asked to pay a total of $210 for physical therapy. ($15/visit x 14 visits = $210). Physical therapy falls within the "Outpatient rehabilitation 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 copayments for physical therapy provided from June 25, 2019 through July 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture.
You asked the Plan to pay for the partial denture. You say that you are in constant pain and cannot eat with your current dentures. You also say that the first dentist refused to fix your dentures because you waited too long to bring them back. The Plan denied your request. The Plan says this plan only covers one lower denture every 5 calendar years. The Plan also says that you have already had this service within the past five years and have reached the limit for this 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, complete or partial dentures are limited to one set every five years. The record shows that you received a mandibular partial denture on August 27, 2018 and your complete or partial denture benefit is now exhausted. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for emergency room services and outpatient surgery provided October 1, 2019 to October 15, 2019.
You asked the Plan to waive the these copayments. You say that you do not believe these copayments are correct. The Plan denied your request. The Plan says these copayments were charged based on the services provided and the copayments stated in the Plan contract.
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 copayments for emergency room services and outpatient surgery. 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 charged for emergency room services and outpatient surgery provided October 1, 2019 to October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found you have a diagnosis of age-related osteoporosis. The documentation is conflicting whether you have an osteoporosis-related fracture. There are no medical records supporting a diagnosis of a current pathological fracture. You have not had a trial of Zoledronic acid. The documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for you. Therefore, you do not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for definitive drug testing (G0482) provided to the enrollee on
June 25, 2019.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization and no medical records were submitted to
show this testing was medically necessary or met the Medicare coverage criteria for this type of testing.
The Plan must follow Medicare rules. Medicare rules say that plans can require enrollees to get care from
network providers. Medicare has specific coverage criteria for definitive drug testing. The contract with the
Plan says that the Plan must 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.
The Plan did not pre-approve this testing. The physicians order and the medical records must specifically show
how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed
to this testing being done for screening purposes. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0482)
provided to the enrollee on June 25, 2019.