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

We decided that the Plan does not have to pay for physician's services provided on January 28, 2020.You asked the Plan to pay for the physician's services.The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 provided on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthopedic shoes (L3216) provided on February 10, 2020.You asked the Plan to pay for orthopedic shoes. You say that this was medically necessary.The Plan denied your request. The Plan says this is not covered under Medicare rules.The Plan must follow Medicare rules. Medicare rules say that with the exception of the situations described above, orthopedic footwear billed using code L3216 will be denied as noncovered. We looked at the file and Medicare rules. The records not show that this footwear is an integral part of a brace or was prescribed for diabetes. Based on this information, we decided that Medicare rules for coverage of orthopedic shoes have not been met.Therefore, we decided that the Plan does not have to pay for orthopedic shoes (L3216) provided on February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea diabetes test kit and test strips.You asked the Plan to pre-approvea  diabetes test kit and test strips. You say that the requested items are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a diabetes test kit and test strips have not been met. Specifically, medical records were not provided. Without this documentation, medical necessity is not able to be established. We have been notified by your provider that you have been prescribed a preferred brand monitor and have since picked it up.Therefore, we decided that the Plan does not have to pre-approvea diabetes test kit and test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe filling, tooth 23 (D2331)comprehensive dental exam (D0150) prophylaxis (D1110)  provided January 11, 2020 to February 15, 2020.You asked the Plan to pay forthe dental services. You say that you received a statement from the dentist that you owe $350. You were told that this dentist was in-network. You would not have taken the dental rider if you knew this dentist was out of network.The Plan denied your request. The Plan says the correct cost-share was 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 $100 deductible and 20% coinsurance after the $100 deductible is met for the dental services. You have been asked to pay $350. The $100 deductible was applied to date of service January 11, 2020. You can get care from an out-of-network dental provider but you may pay more. The services fall within the Dental 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 pay forthe filling, tooth 23 (D2331)comprehensive dental exam (D0150) prophylaxis (D1110)  provided January 11, 2020 to February 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvemitochondrial genome sequencing for the enrollee.You asked the Planto pre-approvethe testing. You say that this is medically necessary, as the results of this test wouldhave significant implications.The Plandenied your request. The Plansaysthere is insufficient scientific evidence to demonstrate that this testing would meaningfully impact the clinical management of the enrollee's condition.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 testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient evidence to show that the requested test would be diagnostic or that it would alter the enrollee's symptom management.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 Plandoes not haveto pre-approvemitochondrial genome sequencing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 28, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 5, 2019 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that you are appealing with supporting documentation.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 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 topay 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 September 5, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCologuard testing (81528).You asked the Plan to pre-approveCologuard testing (81528). You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says you have a family history of colon cancer.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. Medicare says a Cologuardtest is covered if an enrollee is at average risk of developing colorectal cancer, which means the enrollee should not have a family history of colon cancer. The file shows that you have family members with a history of colon cancer. Based on this information, we decided that Medicare rules for coverage of Cologuard testing (81528) have not been met.Therefore, we decided that the Plan does not have to pre-approveCologuard testing (81528).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on February 17, 2020.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 a domiciliary, rest home visit provided on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora sacroiliac joint injection (G0260) provided on February 4, 2020.You asked the Plan to waive the copayment forthe injection. You say that you would like reconsideration because this service has only had a $50 copayment in the past.The Plan denied your request. The Plan says the facility copayment for this service has been 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 $400 copayment for outpatient hospital surgery. You have been asked to pay a $400 copayment for the injection. The injection falls within the outpatient hospital surgery 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 fora sacroiliac joint injection (G0260) provided on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe portable liquid oxygen system provided on January 10, 2020 by an out of network provider.You asked the Plan to pay forthe portable liquid oxygen system. You say that the hospital would not let you leave without an oxygen system.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 itemat issue in this appeal. The Plan did not pre-approve the itemat issue. We found noexception that would requirethe Plan to pay for the item.Therefore, we decided that the Plan does not have to pay forthe portable liquid oxygen system(E0433)provided on January 10, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 13, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided May 22, 2019. You asked the Plan to pay for the orthosis. You say that you are appealing the denial of this claim. Medical records attached. Please reprocess the claim correctly. The Plan denied your request. The Plan says the records provided 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 proof of delivery documentation and an itemized receipt for the items at issue in this appeal. The record does not contain a valid proof of delivery or an itemized receipt for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided May 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transports to and from a physician appointment on September 16, 2019.You asked the Plan to pay for the ambulance transports. You say that because of the enrollee's condition an ambulance is required to transport the enrollee to and from appointments.The Plan denied your request. The Plan says Medicare does not cover ambulance transports to a physician's office.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to and from a doctor's office.Therefore, we decided that the Plan does not have to pay for the ambulance transports to and from a physician appointment on September 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Bi-PAP machine (E0470) and Nebulizer (E0570) provided January 1, 2020 to February 9, 2020.
You asked the Plan to waive the coinsurance for the Bi-PAP machine and Nebulizer. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable Medical Equipment. You have been asked to pay a 20% coinsurance for the Bi-PAP machine and Nebulizer. The Bi-PAP machine and Nebulizer fall within the Durable Medical Equipment 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 a Bi-PAP machine (E0470) and Nebulizer (E0570) provided January 1, 2020 to February 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on March 6, 2020.
You asked the Plan to waive the copayment for the office visit. You say that the doctor didn't discuss any issues. You say that you don't want to pay the bill since you never really had an appointment. 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 for each specialist visit. You have been asked to pay $9.21, which is less than the standard $40 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 March 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for tumor treatment field therapy provided on January 22, 2020.
You asked the Plan to pay for tumor treatment field therapy (E0766). You say that the treatment was medically necessary. The Plan denied your request. The Plan says the records show the enrollee did not have a glioblastoma.
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. This service is not covered for the enrollee's diagnosis. Based on this information, we decided that Medicare rules for coverage of tumor treatment field therapy (E0766) have not been met. Therefore, we decided that the Plan does not have to pay for tumor treatment field therapy provided on January 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from
December 17, 2019 to December 24, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not feel that
you should pay for the second admission to the hospital. 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 $195
copayment for each day for days 1 to 5 for Medicare-covered hospital and a $0 copayment for additional
Medicare-covered days.
You have been asked to pay a $195 copayment for days 1 to 5 of the inpatient hospital stay. ($195 x 5 = $975).
The 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 the inpatient hospital stay provided from December 17, 2019 to December 24,
2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ambulance ride provided on December
30, 2019.
You asked the Plan to waive the cost share for the ambulance ride. You say that you cannot afford this bill.
You say you have never been charged for an emergency before. 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 $300
deductible that applies to ambulance transport and a $100 copayment for each one-way Medicare-covered
ambulance transport after your yearly deductible is met.
The ambulance service you asked the Plan to waive the cost share for falls within "Ambulance services"
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300
deductible that applies towards an ambulance transport and a $100 copayment for each one-way Medicarecovered
ambulance transport after your yearly deductible is met.
This cost sharing is a contractual obligation that had not been met at the time the ambulance transport was
received on December 30, 2019. Therefore, we decided that the Plan does not have to waive the cost share for
the ambulance ride provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunohistochemistry (88342) provided on January 16,
2020.
You asked the Plan to pay for the immunohistochemistry. You say that you would like reconsideration as the
services rendered were medically necessary. The Plan denied your request. The Plan says services that are
considered column II procedures to another service are not eligible for reimbursement when billed with the
column I procedure code.
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, we have confirmed that code the
immunohistochemistry has a bundled relationship with code 88187 and cannot be paid as billed. This code
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been
met. Therefore, we decided that the Plan does not have to pay for immunohistochemistry (88342) provided on
January 16, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the dental services provided on September 10, 2019.You asked the Plan to reimburse you for the dental services. You say that you contacted the Plan and were informed all codes would be covered.The Plan denied your request. The Plan says there does not appeal to be any medical necessity for the teeth extraction and implants.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to reimburse you for involve the removal and replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to reimburse you for the dental services provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 7, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you are
responsible for paying the full cost of services that aren't covered by our plan, either because they are not plan
covered services, or they were obtained out-of-network and 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 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 provided on January 7, 2020.