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

We decided that the Plan does not have to pay for the surgical services rendered on September 10, 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 are not covered.
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 10061 is incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple. We find that CPT code 10061 is not supported in the medical record. Specifically, there is no documentation of an incision and drainage of a complicated or multiple abscess(es). There is a more appropriate code for the documented services. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
The rules say that inpatient pre-operative and intra-operative services are included in the global surgical package.
The provider submitted a claim for procedure code 99222 (initial hospital care) with code 10061. Payment for the inpatient services is included in the global surgical package and has no separate payment.
Therefore, we decided that the Plan does not have to pay for the surgical services rendered on September 10, 2019.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the hyperbaric oxygen therapy. We decided that the Plan does not have to waive the copayment for the office visit. You asked the Plan to waive the cost share for the office visit and hyperbaric oxygen therapy. You say that you were informed the cost was covered by insurance and you would owe nothing out-of-pocket. The Plan says that the cost share applied correctly. We decided that the Plan has to waive the coinsurance for the hyperbaric oxygen therapy. 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 does not say in clear and accurate terms how much you should expect to pay for hyperbaric oxygen therapy. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 15% coinsurance for hyperbaric oxygen therapy. The hyperbaric oxygen therapy is considered a therapeutic service. The Plan contract does not clearly indicate the cost share for therapeutic services beyond therapeutic radiology. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for the hyperbaric oxygen therapy provided from November 11, 2019 through January 3, 2020. We also decided that the Plan does not have to waive the copayment for the office visit.
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 $30 copayment for each in-network, Medicare-covered specialist visit. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for the OON services. You say that the physician depends upon the hospital staff to verify eligibility.The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided on December 9, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient stay provided from November 20, 2019 through November 24, 2019.You asked the Plan to waive the coinsurance for the inpatient stay. You say that you are on a fixed income and are unable to pay.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 each in-network, Medicare-covered hospital stay.You have been asked to pay $1,615.38, which is less than the standard 20% coinsurance for the inpatient stay because you met your maximum out-of-pocket. The inpatient stay falls within the "Inpatient Hospital 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 coinsurance for the inpatient stay provided from November 20, 2019 through November 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services were medically necessary and appropriate. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided on November 3, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a compression sleeve and hand glove.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that surgical dressings are covered when a qualifying wound is present and gradient compression stockings are not covered. We looked at the file and Medicare rules. The file shows that you are requesting a compression sleeve and hand glove for the treatment of lymphedema. There is no documentation of a qualifying wound. 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 pre-approve a compression sleeve and hand glove.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 27369) provided on July 29, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.
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 27369 is "injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography". 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 services. Our reviewer says that the use of a second billed CPT code 27369 is not supported by the records provided. Our physician reviewer found that on the date of service in question, the enrollee received a contrast injection to the left knee for a CT scan. There is no evidence that the enrollee received two contrast injections. The documentation does not support what appears to be duplicate billing of the performed procedure. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 27369) provided on July 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F2 and F5 genetic testing.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. Medicare rules say that F2 and F5 testing is denied as not medically necessary. We looked at the file and Medicare rules. The testing at issue is F2 and F5 genetic testing. This testing is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve F2 and F5 genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nursing facility care (99309) provided on December 17, 2019 by an out of network (OON) provider.You asked the Plan to pay forOON nursing facility care. You say that the hospital staff are responsible for authorization and these services were medically necessary.The Plan denied your request. The Plan says these services were not authorized.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 nursing facilitycare (99309) provided on December 17, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on January 2, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that the ordered scan was approved by the Plan. You say that it was your understanding that the service was covered. 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 $225 copayment for services performed by a provider other than your primary care physician. You have been asked to pay $106.87, which is less than the standard $225 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 the CT scan provided on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on December 4, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network neurologist.
You asked the Plan to pre-approve these services. You say that you would like an out-of-plan opinion. The
Plan denied your request. The Plan says the services are available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network neurologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN).
You asked the Plan to pre-approve IDPN. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered for member with functioning gastrointestinal tract whose need for parental nutrition is due to renal failure and dialysis.
The Plan follows Medicare rules. Medicare rules say that IDPN is covered if the above criteria have been 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 pre-approve IDPN. Our reviewer says that IDPN is not medically reasonable and necessary in this case. There is no evidence that you have a permanently impaired gastrointestinal tract resulting in the insufficient absorption of nutrients to maintain adequate strength and weight. Our physician reviewer found that your condition does not meet criteria for coverage of IDPN. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IDPN have not been met. Therefore, we decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrato
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says this can be received in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the advanced life support services and ambulance ground mileage provided on January 4, 2020
You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice until January 15, 2020. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan says it is the providers responsibility to verify the members coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on January 4, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the advanced life support services and ambulance ground mileage provided on January 4, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on December 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 the services are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on December 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were told initially that you would only have to pay $50 for the ambulance services, however then the complete amount was denied. You were unconscious from your blood glucose going too low. Shortly after receiving treatment from the responders, you came back and you say there was no need for transport. You say that your coverage does not say that the services would not be covered since you were not transported. You stated that previously your Plan has covered the cost minus a copay. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 10, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Stairlift.
You asked the Plan to pre-approve these services. You say that you have arthritis and navigating stairs is difficult. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a Stairlift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automobile transfer seat (E1399) purchased December 20, 2019
You asked the Plan to pay for the automobile transfer seat. You say that this was prescribed by your doctor and is necessary to enter and exit a vehicle. Two representatives told you that this purchase was authorized and covered under your policy as durable medical equipment. The Plan denied your request. The Plan says this item is a non-covered item and the provider is an out of network provider and is not a certified Medicare provider.
The Plan must follow Medicare rules. Medicare rules say that that if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the automobile transfer seat have not been met. Therefore, we decided that the Plan does not have to pay for the automobile transfer seat (E1399) purchased December 20, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for monitoring feature/device (A9279) provided November 29, 2019.
You asked the Plan to pay for monitoring feature/device. You say that the CPAP is to extend your life. You are on a fixed income and cannot afford the monthly payment of $20 . The Plan denied your request. The Plan says payment for this item is incorporated into the payment for the base item, in this case, the CPAP device.
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, we have confirmed that code monitoring feature/device has a bundled relationship with code E0601 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for monitoring feature/device (A9279) provided November 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on July 10, 2019.
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says that any benefits received at a non-network optical provider is excluded.
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 at a network optical provider. We looked at the file and the Plan's rules. The file indicates these services were received out of network. 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 for the eyewear purchased on July 10, 2019.