Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on September 9, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 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 forphysician services provided to the enrollee on September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional blood glucose reagents strips and lancets.You asked the Planto pre-approvethe additional supplies. You say that this is medically necessary.The Plandenied your request. The Plansaysa review of the clinical evidence does not show out of control diabetes.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 additional supplies. Our reviewer says that the requested additional supplies are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided to support the need for more frequent testing.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 additional supplies have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional blood glucose reagents strips and lancets.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea therapeutic continuous glucose monitor and supplies.You asked the Plan to providea therapeutic continuous glucose monitor and supplies. You say that the enrollee has had a system for several months and has shown improvement in glycemic control.The Plan denied your request. The Plan says the enrollee is not on daily insulin or checking blood sugar four or more times a day.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least fourtimes per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day and does notuse insulin.Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor and supplies have not been met.Therefore, we decided that the Plan does not have to providea therapeutic continuous glucose monitor and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine foot care rendered on June 29, 2020.
You asked the Plan to pay for these services. You say that the enrollee has difficulty walking and is unable to
put her shoes on due to pain. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or
feet or have fungal nails.
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for
are routine foot care services. 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 routine foot care
rendered on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 28, 2020 by an out of network (OON) provider.You asked the Plan to pay forurgent care. You say that you were told your primary care provider could not see you, so you went to urgent care.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and you could have been treated within the Plan 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 forthe medical services provided on July 28, 2020by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided on December 27, 2019
by an out of network (OON) provider.
You asked the Plan to pay for durable medical equipment. You say that you would like this claim reprocessed
and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained.
The Play says that the referring provider is also out-of-network. The Plan says that the member's primary care
physician did not refer 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 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 durable medical equipment provided on December
27, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

e decided that the Plan does not have to pay forthe ultrasound rendered on August 20, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 76770 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with theappropriate CPT code.In this case, the CPT Code Manual definition of code 76770 is ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete.We find that CPT code 76770 is not supported in the medical record. Specifically, the documentation supports only one unit of code 76770, which has been paid. 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 forthe ultrasound rendered on August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing.
You asked the Plan to pre-approve the requested testing. You say that the testing was ordered to see if your
daughter's condition was passed from you. The Plan denied your request. The Plan says you do not require
testing due to a personal diagnosis.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The documents in the case file do not show that the results of the test will be used to determine a specific
diagnosis or treatment strategy for you. The test at issue in this appeal is being requested solely for screening
purposes for another individual. Medicare does not cover this test for screening purposes. Therefore, we
decided that the Plan does not have to pre-approve genetic testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 20, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan saysthatthe Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 and the referring provider are not network providerswith the Plan. The Plan did not pre-approve the laboratory services.We found no exception that would require the Plan to pay forthese services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on February 20, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora remote control for a lift chair.You asked the Plan to pay forremote control. You say that without this control unit your chair does not operate.ThePlan denied your request. The Plan says the denial of payment for this item is correct, because this item does not serve a purpose that is primarily medical in nature.The Plan must follow Medicare rules. The rules say that for equipment to be covered,it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pay fora remote control for a lift chair
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forphysical therapy provided from June 11, 2020, through June 23, 2020.You asked the Plan to waive the copayment forphysical therapy. You say that you were told three times that insurance fully covered therapy.The Plan denied your request. The Plan says the copayments 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 $40 per day for Medicare-covered physical therapy services from an in-network provider.You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $160 ($40/visit x 4 visits = $160). Physical 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 copayment forphysical therapy provided from June 11, 2020, through June 23, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe macula risk testing provided on November 19, 2019.You asked the Plan to pay forthe testing services. You say that the records show medical necessity.The Plan denied your request. The Plan says the test was not ordered to treat illness or injury.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The documentation shows that the test predicts progression of age-related macular degeneration. The records do not indicate the services were ordered to determine a specific treatment strategy or diagnosis. The test at issue in this appeal, the testing services, was requested for screening purposes. Medicare does not cover this test for screening purposes.Therefore, we decided that the Plan does not have to pay forthe macula risk testing provided on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a cardiothoracic
surgeon on August 19, 2020.
You asked the Plan to waive the copayment for the cardiothoracic surgery visit. You say that you don't believe
you should have to pay a copayment for this service. The Plan denied your request. The Plan says you were
charged this copayment 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 $50
copayment for specialist visits.
You have been asked to pay a $50 copayment for the cardiothoracic surgery visit. The cardiothoracic surgery
visit falls within the specialist 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 visit you had with a cardiothoracic surgeon on August 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran MRI provided on May 7, 2020.You asked the Plan to waive the copayment foran MRI. You say that the facility your normally go to was closed due to COVID-19 so now you are being billed additional charges for going to an outpatient hospital facility.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 $150 copayment for diagnostic radiology services provided at a hospital for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a $150 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran MRI provided on May 7, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion pump and supplies (A4222, A4221 and E0781) provided on June 3, 2019, through September 9, 2019.
You asked the Plan to pay for the infusion pump and supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the services rendered are inclusive under services approved and paid to the attending Oncologist.
The Plan must follow Medicare rules. Medicare rules say that payment for the administration of the drug or biological billed to the MAC will also include payment for equipment used in furnishing the service. We find that CPT codes A4222, A4221 and E0781 are not supported in the record. Specifically, payment for this equipment is included in the payment to the attending Oncologist. Based on this information, we decided that Medicare rules for coverage of the infusion pump and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the infusion pump and supplies (A4222, A4221 and E0781) provided on June 3, 2019, through September 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory services (81163, 81206, 81292, 81295, 81298, 81301, 81311, 81317) provided on November 26, 2019.You asked the Plan to pay forlaboratory services. You say that this was medically necessary.The Plan denied your request. The Plan says this was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that to report a CGP service, test providers should use CPT code 81479.Welooked at the file and Medicare rules. The record shows that the test at issue is a CGP service and should be billed with 81479. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met.Therefore, we decided that the Plan does not have to pay forlaboratory services (81163, 81206, 81292, 81295, 81298, 81301, 81311, 81317) provided on November 26, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on April 8, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis (L0648). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
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 a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. 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 lumbar-sacral orthosis provided on April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on August 12, 2020.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the servicesat issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to youby an out-of-network provider on August 12, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the purchase of a neurostimulator coded as E0745-NU
provided on May 14, 2020.
You asked the Plan to pay for the neurostimulator as billed. You say that this was a medically necessary item
billed with the correct modifier. The Plan denied your request. The Plan says code E0745 is a capped rental
code and, as such, cannot be billed with the NU modifier.
The Plan must follow Medicare rules. Medicare rules say that capped rental items are paid on a monthly rental
basis.
Code E0745 is designated as capped rental in the durable medical equipment (DME) fee schedule. The DME
fee schedule also does not provide a listing for items billed with E0745-NU. As such, this item cannot be paid
as billed. Therefore, we decided that the Plan does not have to pay for the purchase of a neurostimulator coded
as E0745-NU provided on May 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forultrasounds provided on June 23, 2020.You asked the Plan to waive the copayments forultrasounds. You say that you were not aware that the coverage changed 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 $110 copayment for each radiological diagnostic service.You received two ultrasounds on June 23, 2020. Ultrasounds are considered diagnostic and are subject to cost-sharing charges. Therefore, you are responsible to pay the total allowed amount of $207.68, which is less than the total copayment amount.  You have been asked to pay the total copayment amountof $207.68 for ultrasounds. Ultrasounds 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 forultrasounds provided on June 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the practitioner visit provided on February 19, 2019.
You asked the Plan to pay for the practitioner visit. You say that you did not receive proper notice of the enrollee's benefit determination, which resulted in the untimely submission. You also say that the physician provided medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says the corrected claim was not received until August 31, 2020, which is past the allowed 12 month time frame.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the practitioner visit was not filed until August 31, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the practitioner visit provided on February 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services provided to you on August 8, 2020, and August 15, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe chiropractic services provided to you on August 8, 2020, and August 15, 2020.