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

We decided that the Plan has to pay for genetic testing (81408, 81432, and 81479) provided to the enrollee on September 18, 2020.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says that "based on Medicare Local Coverage Article: Billing and Coding: MolDX: (A55624), Medicare Local Coverage Article: Billing and Coding: MolDX: (A55197), Medicare Local Coverage Article: Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment (A57559), Local Coverage Determination (LCD): MolDX: Biomarkers in Cardiovascular Risk Assessment (L36523), Code of Federal Regulation 42 CFR 410, Subpart B - Medical and Other Health Services (screening tests) and the Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services, these services are not covered."
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. We found that the Medicare regulations cited by the Plan do not apply to the MAC B jurisdiction for Texas. This means the criteria in each of these articles and local coverage determinations do not apply. The Plan has not substantiated its denial. Therefore, we decided that the Plan has to pay for genetic testing (81408, 81432, and 81479) provided to the enrollee on September 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder Detect testing provided on September 24, 2020.
You asked the Plan to pay for the testing services. You say that the testing will be eligible for payment as long as the service meets the medical necessity guidelines. The Plan denied your request. The Plan says the CxBladder Detect is not an approved test.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation. We looked at the file and the rules. In this case, medical records were not provided. There are insufficient medical records to show that the services were ordered for a specific diagnosis or treatment strategy. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder Detect testing provided on September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397)
provided September 11, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were
medically necessary. The Plan denied your request. The Plan says there is no evidence demonstrates the
prescribing physician ever saw the member.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to
the criteria listed in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the knee orthosis and suspension sleeve. Our
reviewer says that the requested items were not medically necessary and reasonable. Our physician reviewer
found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient
credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately
payable when the base item is not covered.
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 knee orthosis and suspension sleeve have not been met. Therefore, we
decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397)
provided September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second lower limb prosthesis.

You asked the Plan to pre-approve lower limb prosthesis. You say that you are not able to do exercise until you get a waterproof prosthesis. The Plan denied your request. The Plan says the denial of authorization for this is correct, because there is no documentation that your current prosthesis meets criteria for replacement.

The Plan follows Medicare rules. Medicare rules state that a replacement lower limb prosthesis may be covered under certain conditions.

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 lower limb prosthesis. Our reviewer says that you do not meet the Medicare criteria for the requested additional lower limb prosthesis. Our physician reviewer found there is no documentation that you have had a physiologic change of status since the time of the original fitting of your prosthesis. There is no evidence that your prosthesis has been damaged or is in a state of sufficient disrepair to require replacement. The requested prosthesis cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lower limb prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a second lower limb prosthesis.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for additional physical therapy.
You asked the Plan to pay for the additional physical therapy. You say that you would like reconsideration because more visits are needed for your ongoing knee issues. The Plan denied your request. The Plan says member is stable with function and capable with home exercise.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the additional physical therapy. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 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 additional physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for additional physical therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on September 25, 2020.
You asked the Plan to pay for CxBladder testing. You say that this testing is eligible for payment as long as the service meets medical necessity guidelines. The Plan denied your request. The Plan says the denial of payment for this testing is correct.
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing code 0012M is non-covered for date of service September 25, 2020. 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 (0012M) provided on September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crowns (D6740 x 2), the pontic (D6245), the core build up (D2950), and the sales tax (D9985) provided from October 15, 2020, to October 20, 2020.
You asked the Plan to pay for the dental services. You say that your book says that dentures and partial dentures are covered. You say that you considered this as a partial denture. You say that you feel that you are being taken advantage of for not understanding this. You say that you are on a fixed income. You also say that you feel that the Plan should cover these services. The Plan denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontic is not listed as a covered service. The Plan says core build up is not listed as a covered service. The Plan also says that sales tax is not payable for services that are not covered.
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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retainer crowns (D6740 x 2), the pontic (D6245), the core build up (D2950), and the sales tax (D9985) provided from October 15, 2020, to October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on June 7, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this claim was not filed timely. The original claim processed on June 20, 2019. However, the corrected claim was not received until September 14, 2020. This is past the allowed 12-month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for this service was not filed until September 14, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on June 7, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on November 12, 2020.
You asked the Plan to waive the copayment for the ambulance ride. You say that you had surgery, was sedated, and could not consent to being transported to a nursing home. The Plan denied your request. The Plan says you have been asked to pay 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 $350 copayment for Medicare-covered ambulance services per trip. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $350 copayment for the ambulance ride.
You have been asked to pay a $234.15 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 ambulance ride provided on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intravitreal injection of a pharmacologic agent, separate procedure (67028) and injection, dexamethasone, intravitreal implant, 0.1 mg (J7312) provided October 3, 2019.
You asked the Plan to pay for the injection services. You say that the records should support the medical necessity of the service in support The Plan denied your request. The Plan says the medical records submitted do not include documentation for the billed service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 67028 and J7312 are not supported in the medical record. Specifically, the records submitted do not indicate that intravitreal injection of a pharmacologic agent was performed. The records do not indicate that injection, dexamethasone, intravitreal implant, 0.1 mg was administered. The records show that the plan made multiple attempts to obtain the additional records. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for intravitreal injection of a pharmacologic agent, separate procedure (67028) and injection, dexamethasone, intravitreal implant, 0.1 mg (J7312) provided October 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from July 25, 2020, to August 28, 2020.
You asked the Plan to waive the copayment for the SNF stay. You say that due to certain circumstances the enrollee had to be inpatient in a SNF for so long. You say you believe the copayment should be waived since the enrollee was forced to be there for so long due to the circumstances. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment per day for days 1-20 of a benefit period and $60 per day for days 21-44 of a benefit period and $0 per day for days 45-100 of a benefit period for each admission. The enrollee has been asked to pay a $1,240 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" 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 for the SNF stay provided from July 25, 2020, to August 28, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on August 4, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you would like to send this bill to your medical card and Medicare. The Plan denied your request. The Plan says you have been asked to pay 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 $120 copayment for emergency services at an emergency room. You have been asked to pay a $120 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 for the emergency room visit provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on
August 6, 2020.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking care.
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 the hospital outpatient clinic visit provided on August 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the two non-invasive extremity arterial studies (Duplex scans) you had on October 20, 2020.
You asked the Plan to waive the copayment for the Duplex scans. You say that you should not be held responsible for this amount because your physician's assistant advised that it was the Plan that said these tests needed to be performed. You say that there was no need for this testing and the tests came back negative. You feel as though the Plan should pay for the tests in full. The Plan denied your request. The Plan says you are responsible for this copayment. The Plan says that you actually should have been charged a separate $125 copayment for each of the Duplex scans (for a total of $250), but because the Plan inadvertently only charged a $20 copayment for one of the scans (and the correct $125 copayment for the other), the Plan is not going to go back and charge the full $250 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 $125 copayment for each radiological diagnostic service, not including x-rays. You have been asked to pay a total of $145 for the two Duplex scans. The Duplex scans falls within the radiological diagnostic service benefit category. These copayments apply regardless of the reason for the tests or the outcome of the tests. 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 two non-invasive extremity arterial studies (Duplex scans) you had on October 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at an alternate level 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower denture (D5120) provided on November 12, 2020.
You asked the Plan to pay for the dental services. You say that you feel you are entitled to benefits. You also say that the entures should be covered as part health care services as they are medically necessary. The Plan denied your request. The Plan says dentures are not covered services.
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 dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower denture (D5120) provided on November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you have been obtaining wipes for over seven years. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies provided.