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

We decided that the Plan does not have to pay for the intrathecal pump refill with analysis and reprogramming (62370) rendered by the out of network (OON) provider on January 8, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was provided by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. 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 the intrathecal pump refill with analysis and reprogramming (62370) rendered by the out of network (OON) provider on January 8, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ferric carboxmaltose infusion, the diphenhydramine HCL infusion and the normal saline solution infusion provided on January 9, 2019. 
 
You asked the Plan to waive the coinsurance for the infusions. You say that you never received a bill for these services in the past. The Plan denied your request. The Plan says that 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 a 20% coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the infusions. The infusions fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the ferric carboxmaltose infusion, the diphenhydramine HCL infusion and the normal saline solution infusion provided on January 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist provided on February 19, 2020. 
 
You asked the Plan to waive the copayment for a specialist. You say that you have never been charged in the past and disagree with the charges. 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 $20 copayment per visit with a specialist.  
 
You have been asked to pay the allowed mount of $10.36, which is less than the $20 copayment for a specialist. A specialist falls within the physician/practitioner services, including doctor's office visits 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 provided on February 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from December 18,
2019 through December 9, 2019.
You asked the Plan to pay for these drugs. You say that you did not self-administer any drugs. The Plan denied
your request. The Plan says that these drugs are not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided from December 18, 2019 through December 9, 2019.
Benefits for these drugs 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: Unfavorable

We decided that the Plan does not have to pay for an MRI provided on January 3, 2020 by an out of network
(OON) provider.
You asked the Plan to pay for an MRI. You say that you would like this claim reprocessed and approved for
payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says the
requesting provider 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 an MRI provided on January 3, 2020 by an out of
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider from September 27, 2019, to December 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was no referral
for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the 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 to the enrollee by an out-of-network provider
from September 27, 2019, to December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and glucose blood test rendered on October 9,
2017.
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 has not been processed by the primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed
that the primary insurer for the date of service at issue was a different carrier. The Plan has not received an
Explanation of Benefits (EOB) from the primary insurer for this claim. As the secondary insurer, the Plan
cannot be held responsible for these services until the primary insurer has denied the claim for these services.
Therefore, we decided that the Plan does not have to pay for the office visit and glucose blood test rendered on
October 9, 2017.
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 disagree with the Plan's decision to deny the
requested foot orthotics. You say that you have a turned leg and you would like the orthotics to be
reconsidered. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management (99239) provided on October 11,
2019.
You asked the Plan to pay for discharge day management. You say that this should be paid. The Plan denied
your request. The Plan says this code 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 99239 is hospital discharge day management; more than
30 minutes.
We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted medical
records do not contain documentation of the time spent on these services, so this time-based code cannot be
verified. Based on this information, we decided that Medicare rules for coverage of discharge day management
have not been met. Therefore, we decided that the Plan does not have to pay for discharge day management
(99239) provided on October 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Pigmented Lesion Assay rendered on November 11, 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 testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that MolDX will reimburse approved tests. 
 
We looked at the file and Medicare rules. The test at issue was not approved through the MolDx program for the date of service at issue. 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 Pigmented Lesion Assay rendered on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on December
3, 2019.
You asked the Plan to waive the copayment for specialist services. You say that you disagree with the out-ofnetwork
charges. 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 $55
copayment for out-of-network physician/practitioner services, including doctor's office visits.
You have been asked to pay a $55 copayment for specialist services. Specialist services fall within the
physician/practitioner services, including doctor's office visits 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 specialist services provided on December 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging and does not
have to waive the coinsurance for a Medicare Part B drug provided on February 18, 2020.
You asked the Plan to waive the copayment for myocardial perfusion imaging and to waive the coinsurance for
a Medicare Part B drug. You say that you were not aware of the charges and cannot afford them. 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 $175
copayment for diagnostic imaging. Your contract with the Plan also clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You received myocardial perfusion imaging on February 18, 2020. Therefore, you are responsible to pay the
$175 copayment.
You received a Medicare Part B drug on February 18, 2020. The allowed amount is $237.12 and 20% of that is
$47.42.
The total amount you owe is: $222.42.
You have been asked to pay the total amount of $222.42 for myocardial perfusion imaging and a Medicare Part
B drug. Myocardial perfusion imaging falls within the outpatient diagnostic tests and therapeutic services and
supplies benefit category. Medicare Part B 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 copayment for myocardial perfusion imaging and does not
have to waive the coinsurance for a Medicare Part B drug provided on February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alcohol rehab services provided to the enrollee on
November 12, 2019.
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your
request. The Plan says there are no records showing a need for physician oversight and detoxification.
The Plan must follow Medicare rules. Medicare rules say that documentation must support the need for
inpatient alcohol rehab services.
Despite multiple attempts, no records have been received from the provider of these services. 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 pre-approve alcohol rehab services provided to the enrollee on
November 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on December 14, 2019 through December 21, 2019. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because CPT code S9328 is payable per CMS. The Plan denied your request. The Plan says CPT code S9328 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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on December 14, 2019 through December 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for external ambulatory insulin delivery systems provided on
September 23, 2019.
You asked the Plan to pay for disposable Omnipods (A9274). You say that you have used the equipment for
years and the supplies are medically necessary. The Plan denied your request. The Plan says drugs and supplies
used with disposable drug delivery systems are non-covered items.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must meet the
definition of durable medical equipment. The OmniPod disposable insulin delivery system does not meet the
definition of Durable Medical Equipment.
OmniPods are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay
for external ambulatory insulin delivery systems provided on September 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 13, 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 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 for the drug testing rendered on December 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard provided on July 24, 2019 by an OON provider. 
 
You asked the Plan to pay for the occlusal guard. You say that you are requesting a dental reimbursement for these services but still have not received a resolution. The Plan denied your request. The Plan says the servicing provider is not contracted with your health plan. The Plan also says that prior authorization was not obtained, and you were not referred by your primary care physician. 
 
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 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 occlusal guard provided on July 24, 2019 by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
December 30, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the claim was billed with an invalid type of bill
for a non-participating home health provider.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim
submitted does not include a valid type of bill code for home health services. Therefore, we decided that the
Plan does not have to pay for the home health services provided to the enrollee from December 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after May 17, 2020. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says you will have reached your 100 day benefit limit for SNF care as of May 17, 2020 and additional days cannot be approved per Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from February 7, 2020 to May 17, 2020. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after May 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide 200 diabetic test strips. 
 
You asked the Plan to provide the diabetic test strips. You say that the items are medically necessary. The Plan denied your request. The Plan says rules for coverage are not 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 provide the diabetic test strips. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is not insulin dependent, and therefore the large quantity of test strips requested is not medically necessary. The standard quantity of 100 test strips and lancets would be reasonable. 
 
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 diabetic test strips have not been met. Therefore, we decided that the Plan does not have to provide 200 diabetic test strips.
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 the enrollee needs the requested orthotics. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.