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

We decided that the Plan does not have to pay for the laboratory services provided on May 28, 2019 by an out ofnetwork provider. You asked the Plan to pay for the laboratory services (88112). You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 thisservice.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on May 28, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on November 4, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you did not go in for an office visit. You say you cancelled your appointment because you were ill. 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 $50 copayment for specialty physician. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Outpatient hospital services" benefit category. The medical record shows you were seen on November 4, 2019 for a chronic anti-coagulation follow-up appointment.
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 specialist office visit provided on November 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the enrollee is bed bound and needs a semi-electric hospital bed. The Plan denied your request. The Plan says there is no clinical documentation supporting criteria.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We looked at the file and Medicare rules. The enrollee's physician has stated that he did not submit authorization or sign the clinical documentation form. The medical documentation does not support medical necessity. Also, Medicare does not provide durable medical equipment in skilled nursing facilities. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forwrist hand orthosis (L3809) provided to the enrollee on November 7, 2019.You asked the Plan to pay forthe orthosis. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.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 the orthosis. Our reviewer says that the enrollee does not meet criteria forthe orthosis ordered. Our physician reviewer found the documentation in the case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the wrist would reasonably be required to adequately assess whether the wrist/hand orthosis was medically reasonable and necessary. The documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this case, as there is no documentation of a credible physical examination of the wrist and hand.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 orthosis have not been met.Therefore, we decided that the Plan does not have to pay forwrist hand orthosis (L3809) provided to the enrollee on November 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneticPro Next Generation Sequencing (NGS) hereditary cancer risk comprehensive genetic panel provided to the enrollee on June 26, 2019.
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your request. The Plan says there is no personal history of cancer, and no indication that cancer biomarker testing was necessary.
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 pay for the testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the
information used to justify this test was not obtained in a traditional fashion. The enrollee does not meet criteria for this screening test. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneticPro Next Generation Sequencing (NGS) hereditary cancer risk comprehensive genetic panel provided to the enrollee on June 26, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the OON psychiatry services. You say that the member specifically requested this provider and would like to see a provider near to his home. The Plan denied your request. The Plan says the requested services are not emergent and the Plan's network can provide this service.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided to the enrollee on April 24, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says prior authorization was not 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 pathology services provided to the enrollee on April 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forMRI provided on July 11, 2019.You asked the Plan to reduce the copayment forthe MRI. You say that you did not know the MRI would have an increased price of $225. You say you have received two MRI's in the past and had a $75 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 $225 copayment for each Medicare-covered complex outpatient diagnostic test including CT, MRI, MRA and nuclear cardiac imaging studies at hospital-affiliated facilities. You have been asked to pay a $225 copayment for the MRI. The MRI fallswithin 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 reduce the copayment forthe MRI provided on July 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Barton H-250 Convertible Chair and Transfer System
You asked the Plan to pre-approve the transfer chair. You say that the enrollee is too heavy for you to move and without the chair you are not able to get the enrollee to appointments. The Plan denied your request. The Plan says after multiple attempts to obtain the required documents the enrollee's doctor did not submit medical notes to show medical necessity.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be medically necessary. There is no documentation on medical necessity or a physician order. Therefore, we decided that the Plan does not have to pre-approve a Barton H-250 Convertible Chair and Transfer System
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that there is nothing in fine print about the denial of payment for ambulance services if the member is not transported. You say you disagree with the Plan's decision that you are responsible for the entire payment of the ambulance response services.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 October 2, 2019. The ambulance benefit is atransportation 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 forthe ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea large volume ultrasonic nebulizer (E0575).You asked the Plan to pre-approve a large volume ultrasonic nebulizer. You say that you are requesting reconsideration of the denial for coverage.The Plan denied your request. The Plan says this item is not a covered.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a largevolume ultrasonic nebulizer have not been met.Therefore, we decided that the Plan does not have to pre-approvea large volume ultrasonic nebulizer (E0575).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance supplies provided on August 15, 2019.You asked the Plan to pay forthe ambulance supplies. You say that the Plan should pay this claim.The Plan denied your request. The Plan says payment for the supplies is included in the payment for the approved ambulance services.Medicare does not pay separately for ambulance supplies. The Plan follows the same rules. We looked at the file and Medicare rules. Ambulance supplies are included in the ambulance fee schedule. Based on this information, we decided that Medicare rules for coverage of the ambulance supplies have not been met.Therefore, we decided that the Plan does not have to pay forthe ambulance supplies provided  on August 15, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forphysical therapy provided from July 1, 2019 through July 24, 2019.You asked the Plan to waive the copayment forphysical therapy. You say that you were informed the provider would receive pre-approval from the Plan. You say that a copayment was never discussed.The Plan denied your request. The Plan says the copayments applied correctly.The rules say aplan 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 each Medicare-covered in-network therapy visit.You have been asked to pay a total of $280 for physical therapy. ($40/visit x 7 visits = $280). 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 July 1, 2019 through July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a ventilator (E0466).
You asked the Plan to pay for the ventilator. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not contain valid proof of delivery for the item at issue.
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 proof of delivery documentation for the item at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The delivery ticket is not signed. Therefore, we decided that the Plan does not have to pay for a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 9, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 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 is not a network provider with the Plan. 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 physician's services that you provided on October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 16, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed services are not supported.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha SureClick.You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this drug is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Repatha SureClick.Benefits for this drug 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: 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 need the requested custom fitted orthotics even though you are not diabetic. You say that the orthotics are needed to help alleviate your plantar fasciitis pain as well as the pain of neuroma. You asked the Plan to provide full coverage of 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 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 foran office visit (99203), and an emotional and behavioral assessment (96127) provided on January 14, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit, and an emotional and behavioral assessment. You say that the supportive documentation will show the need for the services rendered. You provide services to your members in good faith with the expectation of payment and are confident that upon reviewing the facts the claim will be reprocessed for payment.The Plan denied your request. The Plan says the physician is a non-contracted provider. It was verified that the referring provider, is also a non-contracted provider. There was no valid referral on file for the service in question. In addition,the enrollee's services were not urgent or emergent in nature. You do not deny the medical necessity, however, you are upholding the fact that there was no authorization for the service.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 foran office visit (99203), and an emotional and behavioral assessment (96127) provided on January 14, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network dialysis provider for the Enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee has been treated by 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. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network dialysis provider for the Enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown fused to high metal (D2750).
You asked the Plan to pre-approve the dental service. You say that you were not adequately informed at the informational meeting when you signed up for the plan coverage for dental. You say that at the meeting, you were advised there was a maximum of $2,000 for in and out of network dental service. You also say that you called the Plan on December 26, 2019 and were advised that crowns were covered under the facility. The Plan denied your request. The Plan says crowns are not listed as a covered service.
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, crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown fused to high metal (D2750).