Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided on April 26, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
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 provider was approved to bill and ship a dressing set for negative pressure wound therapy (A6550) and a disposable canister for the pump (A7000) under authorization number J19059040. The authorization was from April 24, 2019 through May 14, 2019, and the date of service the products were billed under was April 26, 2019. The claim processed correctly. You are asked to pay 20% coinsurance for the DME. 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 DME provided on April 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cancer genetic testing provided to the enrollee on February 12, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says too little time has passed for another service of this kind to be allowed.
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 pay for the testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the enrollee has a history of diabetes mellitus and colon polyps. The requested test is inclusive for full hereditary cancer gene panel. The records do not include a personal or family history of cancer, concerning signs or symptoms, or rationale for the requested panel. Without the support of the documentation, a broad spectrum panel test is not supported and determined 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 the testing have not been met. Therefore, we decided that the Plan does not have to pay for cancer genetic testing provided to the enrollee on February 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an initial preventive physical exam (G0402) provided on January 16, 2019.
You asked the Plan to pay for the preventive physical exam. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service was billed beyond the 12-month allowed for the benefit period.
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 G0402 is initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment. We find that CPT code G0402 is not supported in the record. Specifically, the record indicates that the member enrolled on January 1, 2017. These services were rendered on January 16, 2019 which is beyond the 12 month allowed benefit period. Based on this information, we decided that Medicare rules for coverage of the preventive physical exam have not been met. Therefore, we decided that the Plan does not have to pay for an initial preventive physical exam (G0402) provided on January 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on March 27, 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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee on March 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster (shingles) vaccine you received on October 7, 2019.
You asked the Plan to pay for the vaccine. You say that the services should have been covered at the doctor's office. The Plan denied your request. The Plan says the service is not covered under your medical benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine you received on October 7, 2019.
Benefits for the vaccine 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 24, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed services are not supported.
The Plan must follow Medicare rules. Medicare rules say that 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. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing 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 April 24, 2019.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Prolia.You asked the Plan to pre-approveProlia. You say that Denosumab is the number one drug to treat cancer-induced bone loss. The Plan denied your request. The Plan says that the enrollee has not tried an oral bisphosphonate drug (alendronate, ibandronate, risendronate) and zoledronic acid.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 physician reviewer found that the enrollee has a diagnoses of malignant neoplasm of prostate and other osteoporosis without current pathological fracture. The enrollee is receiving androgen deprivation therapy, and is at high risk for fracture. The plan's preferred alternatives would likely be less effective, and would be more likely to have adverse effects for the enrollee in this case.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 been met. Therefore, we decided that the Plan has to pre-approveProlia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that you believe corrective orthotics will improve the way you walk.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says that the enrollee does not meet step therapy criteria.
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 Prolia is not medically reasonable and necessary for the enrollee in this case. Prolia is being requested for the treatment of osteoporosis. The enrollee has not trialed zoledronic acid. Additionally, the enrollee has not had an osteoporotic fracture. The documentation does not outline contraindications or reasons zoledronic acid was not considered. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Prolia. 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on March 26, 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 claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on March 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for chemotherapy drugs you received on March 4, 2019.
You asked the Plan to waive the cost share for the drugs. You say that you were told your cost was only $15 copay. The Plan denied your request. The Plan says you are contractually obligated to pay for the drugs.
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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the drugs. The drugs 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 cost share for chemotherapy drugs you received on March 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on June 20, 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 99153 is not separately payable.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. The provider submitted a claim for procedure code 99153 with place of service code 22 for outpatient hospital. This code has a PC/TC status indicator of 3 and no separate PC payment. Payment is included in payment to the facility. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on June 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea semi-electric hospital bed.You asked the Plan to pre-approvea semi-electric hospital bed. You say that the enrollee has had multiple falls and needs a bed that is lower.The Plan denied your request. The Plan says the enrollee does not require bed head elevation, traction equipment, or positioning in ways not feasible in a standard bed.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approvea semi-electric hospital bed.
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 April 22, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records for the billed test.
The Plan must follow Medicare rules. Medicare rules say that 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. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing 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 April 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 7, 2019 through November 8, 2019 provided by an in-network provider.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from November 7, 2019 through November 8, 2019 provided by an in-network provider. You are asked to pay a $250 copayment for inpatient hospital care. 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 copaymentforinpatient hospital care from November 7, 2019 through November 8, 2019 provided by an in-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on March 12, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on March 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing care provided on July 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing care. You say that these services were medically necessary. You say that you would like these services approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the referring facility is also 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 skilled nursing care provided on July 9, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient hospital services provided on May 24, 2018 to November 14, 2018 by an out of network (OON) provider.You asked the Plan to pay forthe inpatient hospital services. You say that this enrollee's care was medically justified as inpatient.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 forthe inpatient hospital services provided on May 24, 2018 to November 14, 2018 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetotal electric hospital bed (E0265).You asked the Plan to pre-approvethe total electric hospital bed. You say that you have problems changing body positions and sleep in due to your medical conditionsThe Plan denied your request. The Plan says this item is not a covered benefit under Medicare or the plan.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvetotal electric hospital bed (E0265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from March 31, 2016 to October 24, 2018.
You asked the Plan to pay for the dental services. You say that you would like to obtain medical and maxillofacial health services coverage of a clearly defined medical iatrogenic illness. The Plan denied your request. The Plan says the services were not authorized, and you self-referred.
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 out-of-network. Medicare allows health plans to restrict enrollees to network providers and require authorization for out of network care. Medicare also generally does not cover dental services. However, your Plan does provide a supplemental dental benefit, and for this reason, the Plan's rules apply. The plan rules state that dental care is only covered when provided by the enrollee's assigned provider dentist.
In this case, you argue that these services should be considered medical because they were needed due to bruxism caused by the use of a medication. However, these services were specifically provided as care, treatment, removal, and replacement of teeth. This means that they meet the definition of dental services and are excluded from Medicare coverage, regardless of the reason that the services became necessary. You received these dental services from providers who were not your assigned dentist. Your Plan only covers services when provided by your assigned dentist. We find that the rules for coverage of the dental care you received have not been met. Therefore, we decided that the Plan does not have to pay for the dental services provided from March 31, 2016 to October 24, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on September 16, 2019.You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment of this service is included in the DRG payment.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger (99190) provided on September 16, 2019.