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

We decided that the Plan does not have to pay for the laboratory services provided on January 30, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services are not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the tests be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre system for the enrollee.
You asked the Plan to pre-approve the requested items. You say that the enrollee has tried and failed many drugs with high levels of uncontrolled diabetes. The Plan denied your request. The Plan says the enrollee does not monitor his blood glucose at least four times a day.
The Plan follows Medicare rules. Medicare rules say that therapeutic continuous glucose monitors are only covered under 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 requested items. Our physician reviewer found that in the case of this enrollee, long-acting insulin was prescribed. Records showed only once daily glucose monitoring prior to receiving the CGM device again. There was no evidence to show that glucose was being checked 4 times daily to show that the full criteria have been met. Therefore, the requested services are not medically reasonable and necessary at this time. 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 requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 24, 2019 by an out of network (OON) provider. You asked the Plan to pay for the office visit (99214). You say that you would like reconsideration because the services were medically necessary. 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 September 24, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 24, 2019 by an out of network (OON) provider. You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 physician services provided on July 24, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services provided by a Certified Surgical Assistant (CSA) on a thyroid lobectomy (60220) on July 31, 2019.
You asked the Plan to pay for surgical assistant services provided by a CSA. You say that this was medically necessary. The Plan denied your request. The Plan says these services are not covered for this type of provider.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided by a Certified Surgical Assistant (CSA) on a thyroid lobectomy (60220) on July 31, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the continuous glucose monitor supply allowance provided on September 26, 2019.
You asked the Plan to pay for the continuous glucose monitor supply allowance (K0553). You say that the supplies were medically necessary. The Plan denied your request. The Plan says that the medical records and Delivery Ticket appear to have been altered.
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 contains a valid physician order and proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan has to pay for the continuous glucose monitor supply allowance
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs (J1815 and A9270) provided on October 17, 2019 through October 18, 2019. You asked the Plan to pay for the self-administered drugs. You say that you would like reconsideration as you were not aware that these services were not covered. The Plan denied your request. The Plan says if you get self-administered drugs that aren't covered by Medicare Part B while in a hospital outpatient setting, the hospital may bill you for the drug. 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 self-administered drugs (J1815 and A9270) provided on October 17, 2019 through October 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the drug tests provided on July 12, 2019 and August 9, 2019.
You asked the Plan to waive the copayment for the drug tests. You say that the doctor submitted the wrong code for both bills. You say that you should be reimbursed. The Plan denied your request. The Plan says the copayments 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 $10 copayment for Medicare-covered lab tests. You have been asked to pay a $10 copayment for each drug test. The total amount you owe is $20 ($10/test x 2 tests = $20). The drug tests fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 drug tests provided on July 12, 2019 and August 9, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the continuous glucose monitor supply allowance provided on August 5, 2019. You asked the Plan to pay for the supply allowance (K0553). You say that the supplies were medically necessary. The Plan denied your request. The Plan says that the medical records and Delivery Ticket appear to have been altered. 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 contains a valid physician order and proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan has to pay for the continuous glucose monitor supply allowance provided on August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve continuous glucose monitor. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee only requires 1 insulin injection per day and has not been checking blood sugar at least 4 times per day.
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are only covered when the 6 criteria listed above are met. If any of these coverage criteria are not met, the continuous glucose monitor will be denied as not reasonable and 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 continuous glucose monitor. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested continuous glucose monitor. Our physician reviewer found the enrollee does not check blood sugar or administer insulin multiple times per day, and he records do not demonstrate a covered indication for continuous glucose monitoring. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services (99282) provided on March 21, 2019.
You asked the Plan to waive the copayment for the emergency room services. You say that you would like reconsideration as you do not believe you should be responsible for this payment. The Plan denied your request. The Plan says this is not a denial and you are responsible for the cost share that 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 $100 copayment for Emergency care. You have been asked to pay a $100 copayment for the emergency room services. The emergency room services fall 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 emergency room services (99282) provided on March 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 26, 2019 through October 30, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that this service should be covered because this was caused by an injury from an accident. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on October 26, 2019 and discharged on October 30, 2019. You were asked to pay a $350 copayment per day from October 26, 2019 through October 29, 2019, days 1-4 of your inpatient hospital care. You were discharged on October 30, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $350 copayment per day required for days 1-5. 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 inpatient hospital care from October 26, 2019 through October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the specialist office visit provided on December 21, 2018.
You asked the Plan to waive the coinsurance for the specialist office visit. You say that you were told several times you were covered. 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 50% of the Medicare-allowed amount for each out-of-network primary care provided visit for Medicare-covered services. You have been asked to pay $114.22 which is 50% of the allowed amount for the specialist office visit. The allowed amount is $228.43. ($228.43 x 50% = $114.22). The specialist office visit falls within "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the provider is out of-network. 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 specialist office visit provided on December 21, 2018.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the periodontal maintenance (D4910) provided on July 31, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that your benefits used to be based on a 12-month period instead of a calendar year. You say that you were not notified that your coverage changed to be based off of a calendar year. You say that the January 2019 appointment should have been processed under the previous year and that the July 2019 appointment should be your first appointment under the 2019 contract. The Plan denied your request. The Plan says that only 2 periodontal maintenance procedures are covered per calendar year. The Plan says that the frequency limit has been exceeded.
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. The Plan did not provide documentation to substantiate the claim that the frequency limit for periodontal maintenance has been exceeded. Therefore, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the periodontal maintenance (D4910) provided on July 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on October 9, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 to the enrollee on October 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on August 30, 2019.
You asked the Plan to waive the copayment for the endoscopy. You say that this was a screening. 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 $350 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay a $350 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that biopsies were performed during the endoscopy, which is considered a surgical procedure. 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 endoscopy provided on August 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on September 14, 2019.
You asked the Plan to pay for the ambulance services. You say that the ambulance service was medically necessary. The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of vehicle.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file, and Medicare rules. The record shows the enrollee, complaining of diarrhea, was conscious, stable, in no acute respiratory or cardiac distress and had no sign of injury, stroke, or hemorrhage. Neither oxygen nor emergency treatment was needed for transport. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for services provided on September 14, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on September 28, 2018.
You asked the Plan to pay for genetic tests. You say that these tests are covered by Medicare and the ordering physician requested these tests as medically necessary. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because these tests are experimental or investigational in nature.
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 a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician is in-network or out-of-network with the Plan, nor does the documentation show that prior notice was given that these tests would not be covered. These tests are not statutorily excluded from Medicare coverage. Without this information, we cannot determine whether the lab requisition made constitutes plan-directed care, which would justify coverage of this claim. Therefore, the Plan has not shown that its denial of payment for these services is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on September 28, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit and skin graft provided on September 25, 2019 and October 3, 2019. You asked the Plan to waive the cost share for the office visit and skin graft. You say that you were informed only this provider could do the procedure. You say that the services should be processed in-network. The Plan denied your request. The Plan says the cost share 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 $65 copayment for provider and professional services at an out-of-network specialist's office and 50% coinsurance for out-of-network surgery services. You have been asked to pay a total of $509.57 for the office visit and skin graft. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The skin graft falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the provider is out-of-network. 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 cost share for the office visit and skin graft provided on September 25, 2019 and October 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four 2D oral/facial photographic images (D0350) provided on November 15, 2019. You asked the Plan to pay for the 2D oral/facial photographic images. The Plan denied your request. The Plan says this service is not a covered benefit. 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 four 2D oral/facial photographic images (D0350) provided on November 15, 2019.