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

We decided that the Plan does not have to pay for the MTHFR gene analysis provided on August 21, 2019.
You asked the Plan to pay for the MTHFR gene analysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The plan uses Local Coverage Determination, LCD L36400 to support their denial. However, LCD L36400 is not valid for the provider's billing address state of Ohio for Medicare Part B. Therefore, we are unable to use LCD L36400 to substantiate our decision.
The Plan must follow Medicare rules. Medicare rules say that genetic testing for the MTHFR gene for all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered except for pregnant patients. Review of the file does not support that the enrollee was pregnant at the time of service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MTHFR gene analysis have not been met. Therefore, we decided that the Plan does not have to pay for the MTHFR gene analysis provided on August 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on March 27, 2019.
You asked the Plan to pay for the hearing aids. You say that it is your understanding that hearing aids are covered by the Plan. The Plan denied your request. The Plan says Medicare does not cover hearing aids and neither does the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for hearing aids provided on March 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services (G0127, 11720, and 99347) provided on April 2, 2019 by an out of network provider.
You asked the Plan to pay for podiatry services. You say that these services were medically necessary. The Plan denied your request. The Plan says these 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 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 the podiatry services (G0127, 11720, and 99347) provided on April 2, 2019 by the out of network provider.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to waive the coinsurance for medical services provided on September 6, 2018.
You asked the Plan to waive the coinsurance for medical service. You say that this is the only place that specializes in his disease. You say that the charges should be covered. The Plan denied your request. The Plan says that the coinsurance applied correctly.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There was no explanation of benefits or claim form submitted with the code at issue to verify the billed services. Therefore, we decided that the Plan has to waive the coinsurance for medical services provided on September 6, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatment for the enrollee.
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have
to pre-approve acupuncture treatment for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumigan eye drops.
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has started samples with
this drug which has helped with his conditions. The Plan denied your request. The Plan says the denial of
authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not
administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Lumigan eye drops.
Benefits for self-administered 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on July 22, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were transported to the emergency room and admitted. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each Medicare-covered one-way trip via ground ambulance. Ground or air ambulance cost sharing is not waived if admitted to the hospital. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to the emergency room. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out of area referral.You asked the Plan to pre-approvean out of area referral. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out of area care. The plan states the requested out of area referral is not due to an unforeseen illness or condition.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  We looked at thefile and Medicare rules. You are requesting to have a quarterly skin check with a qualified physician while you are in Florida. The file does not show that you are requesting this out of area referral due to an unforeseen illness or condition. Based on this information, we decided that Medicare rules for coverage of an out of area referral have not been met.Therefore, we decided that the Plan does not have to pre-approvean out of area referral.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on August 6, 2019 by an out of network provider.
You asked the Plan to pay for the outpatient clinic visit. You say that please reprocess this claim as the provider has been credentialed in network since 05/25/2018. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 the hospital outpatient clinic visit provided on August 6, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNext Generation Sequencing (NGS).You asked the Plan to pre-approvethe NGS laboratory services.. You say that the records provided support the need for NGS.The Plan denied your request. The Plan says the documentation does not support the criteria for coverage have been met.The Plan follows Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) is covered for certain medical indications. 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 NGS laboratory services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of malignant neoplasm of the rectum and an elevated white blood cell count. The enrollee was diagnosed with Stage II rectal cancer in 2006, and was treated with resection, chemotherapy, and radiation. The enrollee received 6 months of adjuvant chemotherapy. The enrollee was referred for hematology/oncology assessment due to leukocytosis and neutrophilia. MyRisk andMyVantage NGS were ordered due to the enrollee's personal history of malignant neoplasm of rectum, and an extensive family of cancer. The documentation does not support that NGS testing is medically reasonable and necessary for the enrollee in this case. The enrollee does not have a diagnosis of recurrent, relapsed, refractory, metastatic, or advanced stage III of IV cancer.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 NGS laboratory services. have not been met.Therefore, we decided that the Plan does not have to pre-approveNext Generation Sequencing (NGS).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on May 8, 2019.
You asked the Plan to waive the copayment for the ambulance services. You say that you could not drive to the hospital so the plan should pay this bill. The Plan denied your request. The Plan says you were charged this cost sharing 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 $225 copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $225 for these services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services provided on May 8, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avo Topical Cream.
You asked the Plan to pre-approve Avo Topical Cream. You say that this cream has worked for your skin
infection. The Plan denied your request. The Plan says this is not a covered benefit.
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 Avo Topical Cream.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test (G0483) provided on June 13, 2019 by an out of
network provider..  You asked the Plan to pay for a drug test. You say that you were not aware of the requirement of obtaining a prior authorization, specifically for this member's plan type at the time of rendering services. You conducted
the toxicology testing ordered by the referring provider in good faith, identifying the services to be medically
necessary. The Plan denied your request. The Plan says based on the member's Evidence of Coverage, the plan
covers emergency or urgently needed care from an out-of-network provider. The Plan says that if the enrollee
needs care that our plan covers and our network providers cannot give it to them, they can get the care from an
out-of-network provider. Prior authorization from the Plan is required for out-of-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 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 a drug test (G0483) provided on June 13, 2019 by an
out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy for decompression of neural elements under image guidance CT, cervical or thoracic (partial removal of bone with release of spinal cord or spinals).
You asked the Plan to pre-approve percutaneous laminotomy/laminectomy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that TIPs, which include procedures that employ the use of a radiofrequency energy source or electrothermal energy to apply or create heat and/or disruption within the disc for the treatment of low back pain, are noncovered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous laminotomy/laminectomy services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy for decompression of neural elements under image guidance CT, cervical or thoracic (partial removal of bone with release of spinal cord or spinals).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 6, 2019 by out of network provider.You asked the Plan to pay foreye examination. You say that the provider did not inform you that they were out-of-network.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 by an in-network provider.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 August 6, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by out of network provider.You asked the Plan to pre-approve office visits. You say that you feel that your condition is urgent and/or an emergency due to the scan results.The Plan denied your request. The Plan says the facility is out-of-network with your benefit plan and in-network providers are available. The Plan says the reason for this decision is yourbenefit plan requires you to receive care from contracted, in-network providers. The Clinic is not contracted with yourinsurance plan. Contracted providers are readily available.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 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. 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-approveoffice visits to be provided by out of network provider,.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on August 14, 2019.You asked the Plan to waive the coinsurance for DME. You say that your surgeon told you not to wear the device 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 20% coinsurance for DME and related supplies. You received DME on August 14, 2019. The allowed amount is $900.00 and 20% of that is $180.00. You have been asked to pay the total coinsurance amount of $900.00 for DME. DME falls within the DME and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharingis 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 forDME provided on August 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee on June 20, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the enrollee has no out-of-network benefits.
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 rendering 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 radiology services provided to the enrollee on June 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95886) provided on May 8, 2019.
You asked the Plan to pay for needle electromyography. You say that this was medically necessary. The Plan denied your request. The Plan says this code is not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for needle electromyography. Our reviewer says that CPT code 95886 is not supported by the medical record. Our physician reviewer found the record does not contain evidence that a complete needle electromyography study was performed during this episode of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95886) provided on May 8, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 23, 2019 through May 25, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decidedthat Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from May 23, 2019 through May 25, 2019.