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

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on November 12, 2020.

You asked the Plan to pay for the testing services. You say that the testing is a covered benefit. The Plan denied your request. The Plan says the enrollee did not meet the coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is only covered under certain medical indications.

We looked at the file and Medicare rules. The records provided do not indicate that the enrollee underwent a previous cancer-negative prostate biopsy within 24 months and was being considered for a repeat biopsy due to persistent or elevated cancer-risk factors. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing provided on November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 13, 2021.
You asked the Plan to waive the copayment for office visit. You say that you could not wait for your appointment and should get your copayment back. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $45 copayment for specialist visit. The record shows that you received a specialist office visit on this date of service; therefore, the specialist copayment applies to this claim. You have been asked to pay $45 copayment for office visit. Office visit 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 an office visit provided on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on January 5, 2021.
You asked the Plan to pay for foot orthotics. You say that this has been prescribed for medical necessity. 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 pay for foot orthotics provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 26, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that the provider relies on the hospital to obtained prior authorization. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's 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 had network providers available who could have provided 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 physician services provided on August 26, 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 subsequent nursing facility care services provided on April 13, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 had network providers available who could have provided 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 subsequent nursing facility care services provided on April 13, 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 wound care provided on November 9, 2020 by an out of network (OON) provider.

You asked the Plan to pay for wound care. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's 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 had network providers available who could have provided 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 wound care provided on November 9, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the abutment supported crown (D6058) and the prefabricated
abutment (D6056) provided on July 30, 2020.
You asked the Plan to pay for the dental services. You say that 2 crowns are covered per year. You say that if
the crown is placed on an abutment then it is not covered. You say that your dentist advised that these were the
exact same service placed on different structures. You also say that you will be looking for other supplement
plans that have better coverage. The Plan denied your request. The Plan says prefabricated abutment is not
listed as a covered service. The Plan says that abutment supported crown is not listed as a covered service
either. The Plan says that implant related services are not covered. The Plan also says that there is no record
that you contacted them prior to the date of service to verify benefits or provider eligibility.
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 dental services you received are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
abutment supported crown (D6058) and the prefabricated abutment (D6056) provided on July 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided on December 3, 2020.
You asked the Plan to pay for the physician services. You say that the service should be covered. 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 also says it is the provider's responsibility to verify the member's 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 December 2, 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 initial hospital care provided on December 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy, 30 minutes (90832) provided on March 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you have rendered treatment to the enrollee in good faith that the service will get reimbursed. The enclosed medical records clearly reflect the medical necessity for the services rendered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 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 had network providers available who could have provided 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 individual psychotherapy, 30 minutes (90832) provided on March 19, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the office visit provided on December 2, 2020.

You asked the Plan to waive the co-payment for the office visit. You say that you should not have to pay a co-payment. The Plan denied your request. The Plan says you were charged this co-payment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 co-payment for Physician Specialist's Office.

You have been asked to pay a $45 co-payment for the office visit. The office visit falls within the Physician Specialist's Office 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 co-payment for the office visit provided on December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required and preventive procedure provided on December 11, 2020.

You asked the Plan to pay for the core buildup and preventive procedure. You say that you cannot afford to pay for these services. The Plan denied your request. The Plan says these services are not covered.

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 pay for the core buildup, including any pins when required and preventive procedure provided on December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided December 2, 2020.

You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that the requested item was medically necessary for the enrollee. The Plan denied your request. The Plan says the medical documentation did not support the member's medical condition to support the medical necessity for the billed supply code.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, there are no medical records which present an adequate history of the enrollee's condition. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided December 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart, without contrast material, with quantitative evaluation of coronary calcium.
You asked the Plan to pre-approve a CT scan of the heart. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that these tests are never covered for screening, i.e., in the absence of signs, symptoms or disease. 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 a CT scan of the heart. Our reviewer says that the services are not medically necessary. Our physician reviewer found qualitative CT coronary calcium scoring is considered a screening service and not a covered service when used in isolation (not as part of a contrast CT angiogram study for possible symptomatic CAD) based on the applicable CMS LCD (L33559) coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the heart have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart, without contrast material, with quantitative evaluation of coronary calcium.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from December 10, 2020, to December 13, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were not aware of your benefits prior to receiving the services. 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 $250 copayment for days 1-7 for inpatient hospital care. 

You had an inpatient hospital stay from December 10, 2020, to December 13, 2020. Therefore, you are responsible to pay a $250 copayment for days 1-3 (December 10, 2020, to December 12, 2020). $250 (copayment) x 3 (inpatient days) = $750.

You have been asked to pay the total copayment amount of $750 for an inpatient hospital stay. An inpatient hospital 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 copayment for an inpatient hospital stay provided from December 10, 2020, to December 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. You say that the physician relies on the hospital to obtain prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the member's 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 had network providers available who could have provided 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 physician services provided on August 28, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on October 8, 2020 by an out of network (OON) provider.
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 were rendered 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 outpatient hospital services provided on October 8, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for introduction and removal procedures on the lungs and pleura (32557) provided October 5, 2020.

You asked the Plan to pay for introduction and removal procedures on the lungs and pleura. You say that please review medical records attached. The Plan denied your request. The Plan says total units billed for procedure exceeds the allowed number of units of 2 in 1 day.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 32557 is 2. You billed 3 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of introduction and removal procedures on the lungs and pleura have not been met. Therefore, we decided that the Plan does not have to pay for introduction and removal procedures on the lungs and pleura (32557) provided October 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 18, 2020.

You asked the Plan to pay for the ambulance services. You say that you were treated in place for COVID symptoms by the medics. 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 18, 2020. 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 provided on November 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for lab services provided from September 28, 2020, to November 2, 2020.

You asked the Plan to waive the copayments for lab services. You say that you were not aware that you had to request the labs to be sent to another location in order to not have a copayment. 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 $40 copayment for lab services provided in an outpatient hospital facility.

You received lab services at an outpatient hospital facility on September 28, 2020. Therefore, you are responsible to pay the $40 copayment. 

You received lab services at an outpatient hospital facility on September 29, 2020. Therefore, you are responsible to pay the $40 copayment. 

You received lab services at an outpatient hospital facility on November 2, 2020. Therefore, you are responsible to pay the allowed amount of $29.68, which is less than the $40 copayment. 

The total amount you owe is: $109.68.

You have been asked to pay the total copayment amount of $109.68 for lab services. Lab services fall 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 copayments for lab services provided from September 28, 2020, to November 2, 2020.