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

We decided that the Plan does not have to pay for a hand finger orthosis provided on October 14, 2019.You asked the Plan to pay for the hand finger orthosis. 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 item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for a hand finger orthosis provided on October 14, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pre-approveperoral endoscopic myotomy (POEM) for the enrollee.You asked the Planto pre-approvethe procedure. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthe enrollee is not in a Medicare-approved study, which is looking at the benefits of POEM in achalasia.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found in the medical literature it has been shown that POEM is an effective treatment modality for Type III achalasia. A recent comprehensive review of the topic suggests that POEM is equivalent or perhaps superior to LHM for achalasia in terms of cost efficiency, hospital length of stay, and relief of dysphagia, with comparable side effects. The Director of Advanced Interventional Endoscopy & Endoscopic Oncology writes that POEM can be used as first line therapy with superior results. The available evidence suggests that POEM is a medically reasonable and necessary treatment option for the enrollee in this case.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 procedure have been met.Therefore, we decided that the Planhas to pre-approveperoral endoscopic myotomy (POEM) for the enrollee.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 16, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the hospital outpatient clinic visit (G0463). You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says utilization of
network providers is required when possible and 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 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 medical services provided on December 16,
2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for chest x-rays provided on December 24, 2019.
You asked the Plan to pay for the chest x-rays. You say that the service was completed three times on the same date of service. The Plan denied your request. The Plan says that the services in dispute require an additional 59 modifier in order to be reprocessed for payment.
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. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code and modifier. We looked at the file and Medicare rules. The records show that the provider billed with a 76 modifier to report repeat chest x-rays provided by the same physician at 3 different times on the date of service in dispute. The rules allow the use of modifier more than once if the procedure is performed more than one time. The health Plan has not provided any information to support their claim that the service needs to be reported with a 59 modifier. The rules allow the use of modifier 76 to report a repeat procedure or service by the same physician and is appended to the procedure to report repeat procedures performed on the same day and/or to indicate that a procedure or service was repeated subsequent to the original procedure or service. Based on this information, we decided that Medicare rules for coverage of the chest x-rays have been met. Therefore, we decided that the Plan has to pay for chest x-rays provided on December 24, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on November 18, 2019.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you were not told you would have a 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 20% of the Medicare-approved amount. You have been asked to pay $826.28 which is 20% of the allowed amount for the Part B injection. The allowed amount is $4,131.40. ($4,131.40 x 20% = $826.28). The Part B injection falls within the "Medicare Part B prescription drugs" 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 the Part B injection provided on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services (92014, 92134) provided on July 8, 2019. You asked the Plan to pay for the ophthalmology services. You say that the service was medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers 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 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 ophthalmology services (92014, 92134) provided on July 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace and sleeves (L1833 L2397 and L0650) provided on January 6, 2020.
You asked the Plan to pay for the knee brace and sleeves. You say that you would like reconsideration because the knee brace is medically necessary. The Plan denied your request. The Plan says the documentation does not show that the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee brace and sleeves have not been met. Specifically, the record indicates that the plan requested notes to indicate that the provider discussed the need for the billed supply code. The submitted documentation does not contain sufficient information regarding the member's medical condition to substantiate the necessity for the type and quantity of items ordered. Therefore, we decided that the Plan does not have to pay for a knee brace and sleeves (L1833 L2397 and L0650) provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the posterior resin-based composite of two surfaces and posterior resin-based composite of three surfaces provided on January 6, 2020.
You asked the Plan to pay for the resin-based composites. You say that it does not say anywhere in your coverage documents that fillings are not covered 100%. You also say that the booklet does not say that resin fillings are not covered. The Plan denied your request. The Plan says a composite resin restoration on a posterior tooth is not a benefit of your dental plan. The Plan also says that you are responsible for the difference in cost up to the maximum approved fee for an amalgam filling.
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, for posterior composite restorations the Plan will pay only the amount that it would have paid to restore the tooth with amalgam. You are responsible for the difference in cost. Therefore, we decided that the Plan does not have to pay for the posterior resin-based composite of two surfaces and posterior resin-based composite of three surfaces provided on January 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the contrast injection and x-ray provided on February 27, 2020 and March 4, 2020. You asked the Plan to waive the copayment for the contrast injection and x-ray. You say that there was an x-ray performed and the visit only lasted 15 minutes. You say that the copayment should be reduced to your x-ray copayment. 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 (suchas copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for an outpatient hospital facility. You have been asked to pay a $400 copayment for the contrast injection and x-ray provided on each date. The total amount you owe is $800 ($400/visit x 2 visits = $800). The contrast injection and x-ray fall within the "Outpatient hospital 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 the contrast injection and x-ray provided on February 27, 2020 and March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on January 15, 2020. You asked the Plan to pay for the pathology 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 and the referring provider are not network providers 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 pathology services provided on January 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on October 15, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that the hospital was not capable of handling her condition. You say that your wife was transferred without a choice.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for each Medicare-covered ambulance service.The enrollee has been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance transport provided on October 15, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on October 17, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the enrollee was on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on October 2, 2019. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the services rendered
on October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 10, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code G0481 is not supported.
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 G0481 is definitive drug testing, 8-14 classes. We find that CPT code G0481 is not supported in the medical record. Specifically, there is no documentation of testing of 8-14 drug classes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the special stain including interpretation and report services provided on December 10, 2019 by an out of network (OON) provider.You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 special stain including interpretation and report services provided on December 10, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 28, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you have $0 copayments. 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 per office visit for Medicare-covered specialist services during an office or telehealth visit. You have been asked to pay a $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 January 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
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 drugs must be supplied by the physician for Part B coverage.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Euflexxa.
Benefits for these services 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran emergency room visit on July 23, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that the copayment 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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the Emergency 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 foran emergency room visit on July 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve autologous hematopoietic progenitor cell (HPC) transplantation (38241).
You asked the Plan to pre-approve autologous HPC transplantation. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that autologous HPC transplantation is covered for the above listed indications. We looked at the file and Medicare rules. The record shows that this is being requested for multiple sclerosis, which is not listed as a covered indication. Based on this information, we decided that Medicare rules for coverage of autologous HPC transplantation have not been met. Therefore, we decided that the Plan does not have to pre-approve autologous hematopoietic progenitor cell (HPC) transplantation (38241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair and accessories.
You asked the Plan to pre-approve a wheelchair and accessories. You say that this wheelchair will be better for
your needs than the wheelchair supplied by the facility. The Plan denied your request. The Plan says the
requested wheelchair is not covered at this time.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that a wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we
decided that the Plan does not have to pre-approve a wheelchair and accessories.