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

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires. The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision care services provided to the enrollee on July 1, 2019 by a non-contracted provider.
You asked the Plan to pay for vision care services. You say that the claim should be paid. The Plan denied your request. The Plan says there was no preauthorization for the service, no referral from Primary care physician, no evidence of a medical emergency and services can be provided in Puerto Rico.
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 vision care services provided to the enrollee on July 1, 2019 by a non-contracted provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract surgery that included an additional lens provided on
July 12, 2019.
You asked the Plan to pay for the lens. You say that the service is medically necessary. The Plan denied your
request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and
eyewear.
The services you asked the Plan to pay for are considered routine vision services or eyewear. Vision supplies,
accessories, and/or service components of another HCPCS vision code (V2797) will be denied as not
separately payable. In addition, your Toric lens appears to be used for astigmatism correction. This is
considered a premium lens package, and Medicare only covers a conventional lens package during cataract
surgery. This is articulated in MLN Matters 3927 and MLN Matters 5527 publications, as well as Medicare
Vision Services fact sheet dated April 2018. The medically necessary portion of the eye surgery for cataract
was appropriately covered.
The denial of the premium lens upgrade is upheld as not a covered service. You also signed a statement at the provider's office prior to services informing you that this lens is not covered. Therefore, we decided that the Plan does not have to pay for cataract surgery that included an additional lens provided on July 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on November 5, 2019 to November 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for therapeutic exercises. You say that these services are performed in good faith for reimbursement. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring 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 therapeutic exercises provided on November 5, 2019 to November 7, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. 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.
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 office visit provided on October 29, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids purchased on September 18, 2019 from a non-participating provider.You asked the Plan to pay forthe hearing aids. You say that you were told thePlay pays $500 for each ear.The Plan denied your request. The Plan says you purchased hearing aids from a non-participating provider.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. The provider is not a participating provider and your EOC clearly states, services covered only when rendered by a Participating Provider.Therefore, we decided that the Plan does not have to pay forthe hearing aids purchased on September 18, 2019 from a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided August 16, 2019.You asked the Plan to pay for the orthosis. You say that the denial is absolutely inappropriate as the provider has not misrepresented any services and you would like an explanation as how this was determined.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelinesThe Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided August 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on August 11, 2019.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that cost sharing is a contractual obligation under the plan and cannot be waived.
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 $200 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip 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 ambulance transport provided on August 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for replacement nasal cushion (A7032) non disposable filter (A7039) replaceable water chamber for humidifier (A7046) provided October 15, 2019.You asked the Plan to pay forpositive airway pressure device supplies. You say that the records should support the necessity of the service in dispute.The Plan denied your request. The Plan says the records do not support the service billed.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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid itemized shipping/billing invoice. The delivery ticket did not include the carrier's tracking number. The proof of delivery did not includean order number or details to corroborate the delivery ticket submitted and was dated prior to the billed date of service.Therefore, we decided that the Plan does not have to pay forreplacement nasal cushion (A7032) non disposable filter (A7039) replaceable water chamber for humidifier (A7046) provided October 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 15, 2019.You asked the Plan to waive the copayment forthe ambulance transport. The Plan denied your request. The Plan says that the claim paid correctly according to your contract.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductiblesand coinsurance). Your contract with the Plan clearly says that you must pay a $375 copayment for each one-way Medicare-covered trip. You have been asked to pay a $375 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered trip 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 forthe ambulance transport provided on December 15, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 5, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you saw a nurse instead of a doctor. You say that your copayment should be $10 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 $45 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $45 copayment for the office visit. The 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 the office visit provided on November 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on October 15, 2019.You asked the Plan to waive the copayment for the ambulance ride. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says 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 clearly says that you must pay a $250 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance Services" 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 ambulance ride provided on October 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on November 8, 2019.
You asked the Plan to waive the copayment for the endoscopy. You say that no surgery was performed. You say that you have never had a deductible for this procedure. 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 $250 copayment for each ambulatory surgical center visit. You have been asked to pay a $250 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers" 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 endoscopy provided on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on December 3, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that this was an annual eye exam. You say that you should not be responsible for the 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 $40 copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye. You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show a medical eye exam was performed. 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 eye exam provided on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ophthalmic biometry provided on December 20, 2019.You asked the Plan to waive the copayment forthe ophthalmic biometry. You say that they did not collect a copayment at the time. You say that this should be part of the global fee for your cataract surgery.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 $20 copayment for in-network, Medicare-covered outpatient diagnostic procedures or tests.You have been asked to pay a $20 copayment for the ophthalmic biometry. The ophthalmic biometry falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. There is no provision in the contract which indicates a copayment would be waived for services performed as a follow-up to a surgical procedure. 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 forthe ophthalmic biometry provided on December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted neurological or neuromuscular diagnostic procedure
You asked the Plan to pay for other Neurology and Neuromuscular procedures. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records do not support the billed services.
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 unlisted neurological or neuromuscular diagnostic procedure 95999 is Unlisted neurological or neuromuscular diagnostic procedure. 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 other Neurology and Neuromuscular procedures. Our reviewer says that the procedure code billed does not meet the criteria for billing or reimbursement consideration. Our physician reviewer found train of four testing does not fit the criteria set by CMS, AMA and Insurance Carriers for CPT 95999. Hence it is inappropriate to bill unlisted neurological or neuromuscular diagnostic procedure code for train of four monitoring. There is no separate code for train of four monitoring. Train of four monitoring is bundled with intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials (MEP) and should not be reported separately. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of other Neurology and Neuromuscular procedures have not been met. Therefore, we decided that the Plan does not have to pay for unlisted neurological or neuromuscular diagnostic procedure
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for infrared therapy (97026) provided on November 25, 2019 through December 13, 2019.
You asked the Plan to waive the coinsurance for the infrared therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says you may receive all plan covered services from non-network providers, but you will have to pay a higher cost sharing than the one you pay when using in network providers.
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 outpatient rehabilitation services. You have been asked to pay 20% coinsurance for the infrared therapy. The infrared therapy falls within the outpatient rehabilitation services 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 infrared therapy (97026) provided on November 25, 2019 through December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network sleep specialist.
You asked the Plan to pre-approve these services. You say that you would prefer to see this provider. 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. The file shows that the requested provider is located 124 miles
from your residence and the in-network provider is available 119 miles from your residence. Therefore, we
decided that the Plan does not have to pre-approve a referral to an out-of-network sleep specialist.