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

We decided that the Plan does not have to pay for injection supplies (A4221, E0781, A4222) provided from July 6, 2020 to July 20, 2020.
You asked the Plan to pay for injection supplies. You say that these items should be covered. The Plan denied your request. The Plan says these items are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that with the two exceptions listed in the Medicare Claims Processing manual, Medicare does not make a separate payment for supplies furnished in connection with a procedure. We looked at the file and Medicare rules. The items at issue were supplies furnished in connection with a procedure and do not meet the requirements for separate payment. Based on this information, we decided that Medicare rules for coverage of injection supplies have not been met. Therefore, we decided that the Plan does not have to pay for injection supplies (A4221, E0781, A4222) provided from July 6, 2020 to July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral periapical x-rays provided on November 28, 2018 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral periapical x-rays. You say that you cannot afford to pay this bill. The Plan denied your request. The Plan says these services were rendered by an OON dentist. The Plan also says that you must receive care from an in-network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation and complete series of intraoral periapical x-rays provided on November 28, 2018 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient diagnostic tests provided on October 12, 2020.
You asked the Plan to waive the copayments for the duplex scan of extracranial arteries, duplex scan of aorta, and limited bilateral noninvasive physiologic studies. You say that you have never paid for these tests before. The Plan denied your request. The Plan says you were charged these copayments 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 $25 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $75 copayment for the duplex scan of extracranial arteries, duplex scan of aorta, and limited bilateral noninvasive physiologic studies. The duplex scan of extracranial arteries, duplex scan of
aorta, and limited bilateral noninvasive physiologic studies fall within the Outpatient Diagnostic Tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for outpatient diagnostic tests provided on October 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from December 1, 2020, to December 3, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you needed these medications. The Plan denied your request. The Plan says the self-administered drugs may be payable under Medicare Part D, but are not payable 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 drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from December 1, 2020, to December 3, 2020.
Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided October 28, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like the service covered. The Plan denied your request. The Plan says this service was previously covered in 2019 and therefore the current claim is not eligible for coverage by the Plan at this time.
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. The Plan covers the comprehensive oral evaluation once every three plan years. We looked at the file and Medicare rules. The Plan provided documentation that this service was previously covered on November 7, 2019. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasound guidance for vascular access (76937) critical care, first hour (99291) endotracheal intubation, emergency (31500) insertion of central venous catheter for infusion (36556) provided November 9, 2020.
You asked the Plan to pay for the emergency services. You say that you would like to appeal the non-payment by the plan for this claim. The Plan denied your request. The Plan says this is a duplicate of a previously paid claim.
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 find that CPT code is not supported in the medical record. Specifically, this is a duplicate of a paid claim billed by the same provider for the same date of service. The claim was not billed with a modifier that would allow for additional payment. Based on this information, we decided that Medicare rules for coverage of the emergency services have not been met. Therefore, we decided that the Plan does not have to pay for ultrasound guidance for vascular access (76937) critical care, first hour (99291) endotracheal intubation, emergency (31500) insertion of central venous catheter for infusion (36556) provided November 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit (Q5106).
You asked the Plan to pre-approve Retacrit. The Plan denied your request. The Plan says the off-label use of this drug for the enrollee's condition is not medically accepted per Medicare rules and is not covered based on available information.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Retacrit. Our reviewer says that Retacrit is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the requested use of Retacrit is FDA-approved for the enrollee's diagnoses. Our reviewer found that the use of Retacrit for anemia of chronic disease related to lupus and vitamin B-12 deficiency is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal. Our physician reviewer also found that the use of Retacrit for anemia of chronic disease related to lupus and vitamin B-12 deficiency is not indicated, supported or recommended in any of the compendia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit (Q5106).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endoscopy (43235) provided August 19, 2020.
You asked the Plan to waive the copayment for the endoscopy. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment 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 $250 copayment for outpatient surgical center services.
You have been asked to pay a $250 copayment for the endoscopy. The endoscopy falls within the outpatient surgical center 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 an endoscopy (43235) provided August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for room and board at a motel while attending a clinical trial from October 4, 2020, to November 25, 2020.
You asked the Plan to reimburse you for the motel stay. You say that you had to pay to stay at a motel during the clinical trial. You say that you were encouraged to be within 15 miles of the hospital. You say that you live 120 miles from the hospital involved in the clinical trial. You also say that your social worker and doctors advised that this would be covered. The Plan denied your request. The Plan says this service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the clinical trial room and board have not been met. The Plan must follow Medicare rules.
Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the motel stay have not been met. Specifically, Medicare only covers room and board for a hospital stay during a clinical trial. Motel and lodging costs are not a Medicare or Plan covered benefit. Therefore, we decided that the Plan does not have to reimburse you for room and board at a motel while attending a clinical trial from October 4, 2020, to November 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic.
You asked the Plan to pre-approve Ozempic. The Plan denied your request. The Plan says this medication does not fall 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 drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.
Benefits for Ozempic 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital hearing aids (V5261) provided on December 17, 2020.
You asked the Plan to pay for the hearing aids. You say that you called the Plan to verify that this enrollee had out-of-network coverage for hearing services, and you were told that they would be covered. The Plan denied your request. The Plan says hearing aids will only be covered up to $2,000 when they are purchased from the Plan's specified hearing provider as stated in the contract.
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. The Plan pays for hearing aids only when they are purchased from the Plan's specified hearing provider. 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. Therefore, we decided that the Plan does not have to pay for the digital hearing aids (V5261) provided on December 17, 2020.
Your complaint about potential misinformation from the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from January 17, 2021, to January 18, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you feel the Plan should pay for the self-administered drugs because you were not allowed to bring your own medications with you. The Plan denied your request. The Plan says self-administered drugs are not Part B covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from January 17, 2021, to January 18, 2021.
Benefits for the self-administered drugs 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, gastrointestinal tract, upper (74246, 74240) provided December 14, 2020.
You asked the Plan to pay for the diagnostic services. You say that a nurse practitioner started the procedure, and you drank the barium but some of it went into your lungs and they shut things down after that. You do not believe you should have to pay these charges, but you will if you have to. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 deductible. This is the amount you must pay out of pocket before the plan will pay their share of covered services. Until you have paid the deductible, you must pay the full cost of your covered services. The item or service you asked the Plan to pay for falls within the benefit category Outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible. This cost sharing is a contractual obligation that had not been met at the time the diagnostic services was received on December 14, 2020. Therefore, we decided that the Plan does not have to pay for radiologic examination, gastrointestinal tract, upper (74246, 74240) provided December 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0013M) provided on December 8, 2020.
You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0013M) provided on December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous glucose monitor supplies (K0553) provided January 2, 2021.
You asked the Plan to pay for the continuous glucose monitor supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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 does not contain relevant medical records which support medical necessity for the supplies provided in this case. 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 continuous glucose monitor supplies (K0553) provided January 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on February 18, 2021.
You asked the Plan to waive the copayment for specialist services. You say that you were only on the phone for 5 minutes. You say that you were told that they could not provide the services you needed. The Plan denied your request. The Plan says the correct copayment has been 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 $25 copayment for physician/practitioner services/in-network/specialist. You have been asked to pay a $25 copayment for specialist services. Since a telehealth call was provided, the
correct copayment has been applied. Specialist services fall within the physician/practitioner services/in-network/specialist 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 specialist services provided by a participating provider on February 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitors (CGM) supply allowance
(K0533), provided on January 2, 2021.
You asked the Plan to pay for a CGM supply allowance. You say that the item is medically necessary. The Plan
denied your request. The Plan says there is insufficient medical documentation indicating the medical necessity
of this item.
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and
necessary for enrollees with diabetes who meet the criteria referenced above.
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 CGM supplies allowance. Our reviewer says
that the item is not recommended. Our physician reviewer found there is insufficient documentation indicating
the medical necessity of this item.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CGM supplies allowance have not been met. Specifically, there is not enough
evidence to support the medical necessity of a CGM supply allowance, and therefore, the item is not covered.
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitors (CGM) supply
allowance (K0533), provided on January 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flex-walk system, multiaxial ankle system, and vacuum system for prosthesis.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that the enrollee is a K3 ambulator, given that the expected assistive device is handrails, and the enrollee walks slowly without an assistive device and is much faster with a cane. The flex walk and multiaxial ankle system exceed the enrollee's functional level, as these require a K3 level, which is not supported in the documentation. The documentation does not support that the enrollee requires the volume management system, as there is no evidence of edema on the treating medical provider exam. Additionally, there is no evidence that the enrollee has skin irritation from sweating and requires the vacuum system per the treating medical provider progress notes. The vacuum system exceeds the enrollee's medical need. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a flex-walk system, multiaxial ankle system, and vacuum system for prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor and supplies (K0553, K0554) provided January 14, 2021.
You asked the Plan to pay for the continuous glucose monitor and supplies. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the request is missing required documentation.
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. Review of the file shows that the proof of delivery did not include an itemized order form or invoice to indicate the specific supplies; therefore, the billed supply code cannot be verified. 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 continuous glucose monitor and supplies (K0553, K0554) provided January 14, 2021.