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

We decided that the Plan does not have to pay foran extra battery and chargerand back pack for a special portable oxygen system (also called an oxygen concentrator) provided from July 10, 2019 through July 29, 2019.You asked the Plan to pay forthe DME. You say that you are appealing the denial of payment issued in connection with your DME claim for additional battery packs for your portable oxygen machine.The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan states for you, the additional accessories (battery, charger and backpack) for your portable oxygen concentrator are not needed in the home. The Plan states you have a portable oxygen system and a home oxygen system with the batteries and chargers; therefore, the back pack is not covered by Medicare.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DMEhave not been met. While a beneficiary may use their DME outside of the home, the criterion used to determine DME coverage is based solely on the in-home need. The reasons cited as to why you need the requested additional portable oxygen battery and charger and back pack are all for use of this concentrator outside of the home.Therefore, we decided that the Plan does not have to pay foran extra battery and charger and back pack for a special portable oxygen system (also called an oxygen concentrator) provided from July 10, 2019 through July 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe standard wheelchair provided on September 23, 2019.You asked the Plan to pay forthe standard wheelchair. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the supplierdid not request prior authorization.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 standard wheelchair provided on September 23, 2019
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided from August 13, 2019 through August 14, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that the charge is outrageous for the level of care received. You say that you should not pay this 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 a $65 copayment for each emergency room visit. You have been asked to pay a $65 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ED visit provided from August 13, 2019 through August 14, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided on June 19, 2019.You asked the Plan to waive the copayment foran ultrasound. You say that you disagree with the charges because you feel the services were preventative.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 $5 copayment for a diagnostic ultrasound. You have been asked to pay a $5 copayment for an ultrasound. An ultrasound 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 isa 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 foran ultrasound provided on June 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on April 10, 2019 by out-of-network provider, "the medical center". You asked the Plan to pay forthe out-of-network services. The Plan denied your request. The Plan says the services received were not urgent, emergent, and 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 lab 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 out-of-network services. Therefore, we decided thatthe Plan does not have to pay forthe lab services provided on April 10, 2019 by out-of-network provider,"the medical center".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forfoot, insert, removable, molded to patient model, 'ucb' type, berkeley shell, each (CPT Code L3000) provided on September 5, 2019.You asked the Plan to pay forfoot orthotics. You say that you had two previous surgeries and since then you have developed a resistant condition.The Plandenied 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 Planfollows 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 pay forfoot, insert, removable, molded to patient model, 'ucb' type, berkeley shell, each (CPT Code L3000) provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine you received on September 3, 2019.You asked the Plan to pay for the vaccine. You say that you needed to take necessary precautions to care and support your granddaughter.The Plan denied your request. The Plan says a tetanus vaccine is not covered as a preventive service.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. 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 Tetanus, diphtheria toxoids and acellular pertussisvaccine (Tdap) vaccine you received on September 3, 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for an office visit provided on August 27, 2019.
You asked the Plan to waive the copayment for the office visit. You say that your doctor told you that you would not have to pay for follow-up visits after you get discharged from the hospital. The Plan denied your request. The Plan says that you have been charged the correct cost sharing 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 does not say in clear and accurate terms when you should expect to pay for each covered visit or consultation in an outpatient location with your PCP or other primary care physician as a follow-up visit for a hospitalization. We looked at your contract with the Plan. We did not see where the contract explains the criteria for a follow-up visit. The Plan contract does not clearly say when the $0 follow-up copayment would apply and when the $10 PCP copayment would apply. 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 copayment for an office visit provided on August 27, 2019.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging services.You asked the Plan to pre-approve the myocardial perfusion imagingservices. You say that the records provided support the need for the requested service.The Plan denied your request. The Plan says the enrollee has no current heart symptoms.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 the myocardial perfusion imaging services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has some coronary risk, no anginal symptoms, and electrocardiogram showing possible septal myocardial infarction but normal wall motion and normal ejection fraction on echocardiography. The normal echocardiogram makes the electrocardiogram likely a false positive and, in the absence of chest pain, no further evaluation with cardiac testing is medically necessary. Furthermore, if stress testing were thought to be medically necessary then routine treadmill electrocardiography should be sufficient. Coverage criteria for nuclear stress testing is not met since there are no documented covered indications for the 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 myocardial perfusion imaging services have not been met.Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 26, 2019, by an out-of-
network provider.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the provider is out-of-network and did not obtain an authorization. The Plan states the
services were not referred by a participating provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 May 26, 2019,
by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Zio Patch cardiac monitor to be provided by out of network provider, iRhythm.You asked the Plan to pre-approvethe Zio Patch cardiac monitor. You say that you need the Zio Patch cardiac monitor. The Plan denied your request. The Plan says your doctor has not submitted medical records as to why this specific heart monitor is needed and there are in-network providers that can provide this service.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 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-approvethe Zio Patch cardiac monitor to be provided by out of network provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation services.
You asked the Plan to provide additional routine transportation trips. You say that you need transportation to your dentist and PCP and cannot take public transportation. The Plan denied your request. The Plan says you have used all of your transportation benefit for 2019.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of additional routine transportation trips. Therefore, we decided that the Plan does not have to provide additional routine transportation services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 16, 2019 by the out of network provider.
You asked the Plan to pay for laboratory tests. You say that you would like the documents reviewed. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says the facility is out-of-network. The Plan says that the member was self-directed.
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 August 16, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory services (89051, 87075, 87205, 87070) provided on January 11, 2019 by out of network provider.You asked the Plan to pay forlaboratory services. You say that SCAN should be responsible for the funds owed in this claim. You say you do not feel responsible for this bill. You further say that if you had not lost your  insurance by signing up with SCAN that the plan would have paid for it.The Plan denied your request. The Plan says you must receive care from a network provider and in most cases, care received from an out-of-network provider will not be covered, except for the following: emergency care or urgently needed service and needed medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care. The Plan says further that authorization is required.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 providerin 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 thePlan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forlaboratory services (89051, 87075, 87205, 87070) provided on January 11, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four porcelain or ceramic retainer crowns and two porcelain or ceramic pontics.You asked the Plan to pre-approvethe retainer crowns and pontics. You say that your mouth is in pain and you need these services to resolve the issues.The Plan denied your request. The Plan says these services are not covered under your benefit package.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 pre-approve four porcelain or ceramic retainer crowns and two porcelain or ceramic pontics.
Appeal type: Lab
Decision: Favorable

We decided that the Planhasto pay forthe professional component (interpretation) of the surgical pathology services provided on July 11, 2019.You asked the Planto pay forthe pathology interpretation. You say that Medicare does pay for the professional component of pathology services which are done in the outpatient hospital setting. There is no reason payment cannot be made for the PC when billed with POS code 22.The Plandenied your request. The PlansaysthatAccording to our policy, which is based on CMS Policy, the technical and professional components of a laboratory test are payable to and included in the payment to the facility in which the services were rendered. Physicians may not bill or be separately paid for the technical and/or professional components of laboratory services performed in a facility setting.The Plan must follow Medicare rules. Medicare rules say that payment may be made for the professional component of pathology services furnished to hospital patients. We looked at the file and Medicare rules. The Plan's citation of the rules is not in accordance with known CMS policy. There is no valid citation provided to support that the PC of the pathology is not payable in this setting.Therefore, we decided that the Planhas to pay forthe professional component (interpretation) of the surgical pathology services provided on July 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Biofreeze topical pain relief.You asked the Plan to pre-approveBiofreeze topical pain relief. You say that you are in constant pain and need Biofreeze but you cannot afford it.The Plan denied your request. The Plan says Biofreeze topical pain relief is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and Biofreeze topical pain relief is an OTC item.Therefore, we decided that the Plan does not have to pre-approveBiofreeze topical pain relief.
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 in-network doctors listed in the denial have not been able to provide you with an adequate solution to your medical condition. The Plan denied your request. The Plan says your plan requires you to receive care from providers who are part of your primary care physician's (PCP) specialty 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 pre-approved care. The contract with the Plan also says that your plan requires you to receive care from providers who are part of your primary care physician's (PCP) specialty network.
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 the requested services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of torus palatinus.
You asked the Plan to pre-approve the removal of torus palatinus. You say that you need this surgery in order to get dentures. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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 pre-approve the removal of torus palatinus.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for breast tomosynthesis (77061) provided on August 26, 2019.
You asked the Plan to pay for the breast tomosynthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says procedure code 77061 has a status code of I which is not valid for Medicare purposes.
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 CPT code 77061 is not supported in the medical record. Specifically, per the 2019 Physician Fee Schedule, 77061 has a status code of I. This means that 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for breast tomosynthesis (77061) provided on August 26, 2019.