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

We decided that the Plan does not have to pay for the drug testing rendered on December 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 the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on May 8, 2020 with major depressive disorder. Based on the submitted records, it is not expected that he will improve in a reasonable period of time beyond the dates in question, as he is not showing any dangerousness to himself or others and has no auditory or visual hallucinations. He is not showing aggressive behavior. He does not have suicidal or homicidal ideations. It does not appear that active treatment is taking place beyond the dates in question. The continued services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 26, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says there is no valid referral for this service.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 laboratory services provided on November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on February 6, 2020.
You asked the Plan to pay for the drug test. 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 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 a drug test provided on February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are requesting coverage for custom
orthotics to help you walk. You say that the orthotics will help reduce the pain that you go through every day
along with your other medical issues. You stated that you are retired and it is difficult for you to financially
afford the medical hardware that you need. You asked the Plan to reconsider coverage of the requested
orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 25, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
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
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 physician's services provided on February 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for MRIs (72148 and 73221) provided on October 25, 2019 through November 16, 2019. You asked the Plan to pay for the MRIs. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for MRIs (72148 and 73221) provided on October 25, 2019 through November 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for breast augmentation (19325) provided on October 28, 2019.
You asked the Plan to pay for breast augmentation. You say that this was medically necessary. The Plan denied your request. The Plan says this was cosmetic.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. The rules also say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 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 breast augmentation. Our reviewer says that the documentation does not support that this was medically necessary. Our reviewer found there is insufficient documentation to provide an adequate judgement. Photographs are critical to determining the medical necessity of the bilateral breast augmentation. Therefore, medical necessity cannot be adequately determined based on the provided medical documentation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of breast augmentation have not been met. Therefore, we decided that the Plan does not have to pay for breast augmentation (19325) provided on October 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 16, 2019.
You asked the Plan to pay for drug test. You say that the provider can do a better job of submitting claims for
these services so that they are not denied. The Plan denied your request. The Plan says the denial of payment
for this service is correct, because a maximum of 1 drug test may be submitted and paid per patient per date of
service.
The Plan must follow Medicare rules. Medicare rules say that a maximum of 1 presumptive urine drug test may
be submitted and paid per patient per date of service.
We looked at the file and Medicare rules. The record shows that this provider took a sample for testing by an
independent laboratory which was processed and paid by the Plan with no liability for you. However, this
provider also performed the same testing in-office which means that the frequency limit of 1 test per patient per
date of service was exceeded. Based on this information, we decided that Medicare rules for coverage of drug
test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on
December 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora mammogram (77063, 77067) provided November 7, 2019.You asked the Plan to pay forthe mammogram. You say that the mammogram should be covered.The Plan denied your request. The Plan says a screening mammogram was already provided within the past 12 months. A second screening mammogram is not covered, therefore a diagnostic mammogram was billed appropriately.The Plan must follow Medicare rules. Medicare rules say that payment may be made for a screening mammography performed after at least 11 months have passed following the month in which the last screening mammography was performed.We looked at the file and Medicare rules. A screening mammogram was already coveredon April 17, 2019. Based on this information, we decided that Medicare rules for coverage of the mammogram have not been met.Therefore, we decided that the Plan does not have to pay fora mammogram (77063, 77067) provided November 7, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound, CT scan and a biopsy provided on January 14, 2020 to January 21, 2020.
You asked the Plan to waive the copayment for an ultrasound, CT scan and a biopsy. You say that these copayments are too high. You say that you would like these copayments waived. The Plan denied your request. The Plan says the correct copayments have been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay an $110 copayment and a $150 copayment for outpatient diagnostic tests/non-radiological diagnostic services outpatient surgery/outpatient surgery at outpatient hospital. You have been asked to pay an $110 copayment for a CT scan, a $108.17 copayment for an ultrasound and a $150 copayment for and a biopsy. The total amount you are being asked to pay is $368.17 ($110 + $108.17 + $150 = $368.17). An ultrasound and a CT scan falls within the outpatient diagnostic tests/non-radiological diagnostic services benefit category and a biopsy falls within outpatient surgery/outpatient surgery at outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound, CT scan and a biopsy provided on January 14, 2020 to January 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on April 2, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that you qualified for an annual CT scan for lungcancer screening. You say that you were informed the copayment would be waived.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 sharinginformation (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for CT scans, MRI's, PET scans and nuclear cardiac imaging tests. You have been asked to pay $118.77, which is less than the standard $325 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The CT scan is considered diagnostic imaging. 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 forthe CT scan provided on April 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 31, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were available in-network.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 services at issue in this appeal. 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 medical services provided to the enrollee by an out-of-network provider on December 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation to attend medical appointment.The Plan denied your request. The Plan says that you have exceeded your plan benefit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of twenty-four (24) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foran outpatient surgery provided by an out-of-network provider on December 30, 2019.You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you were not aware that this provider was out-of-network. The Plan denied your request.The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% coinsurance for outpatient surgery/out-of-network. You have been asked to pay a 50% coinsurance for an outpatient surgery. an outpatient surgery falls within the outpatient surgery/out-of-network 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 an outpatient surgery provided by an out-of-network provider on December 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided January
7, 2020 to February 5, 2020.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for the SNF
services. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of
coverage were not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily
basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for the skilled nursing facility (SNF) services provided January 7, 2020 to February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power mobility device.
You asked the Plan to pre-approve a Group 1 power mobility device. You say that because of health conditions
you need a power scooter. The Plan denied your request. The Plan says there is no physical therapy evaluation
or home evaluation.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
The file does not show you have a mobility deficit that impairs your participation in MRADLs, your condition
cannot be improved by a walker, cane or manual wheelchair, or that you can safely operate the PMD being
requested. There is no Face-to-Face documentation or Home Assessment documentation. This means that
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to
pre-approve a Group 1 power mobility device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewing x-rays provided (D0274) on January 28, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plandenied your request. The Plan says bitewing x-rays are payable once every twelveconsecutive months.You were not eligible for bitewing x-rays on this date of service.Medicare generally does not cover dental services. However, the Plan offers a dentalbenefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of this service have not been met.Specifically, you have exceeded the allowablebenefitas you previously received bitewing x-rays on February 13, 2019, less than twelve months prior to thedate of serviceappealed.The benefit allows for one set of bitewing x-rays to be covered every twelvemonths.Therefore, we decided that the Plan does not have to pay forthe bitewing x-rays provided (D0274) on January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin partial mandibular denture base repair (D5611) provided on January 17, 2020. You asked the Plan to pay for the resin partial mandibular denture base repair. You say that this service should be covered because it should have been provided in 2019, when it was a covered benefit. You also say that you are on a fixed income and did not receive this service because you were unhappy with the in-network providers. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 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 resin partial mandibular denture base repair (D5611) provided on January 17, 2020. Your complaint about your unhappiness with the in-network providers is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that you were not aware of the requirement of obtaining prior authorization. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
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 February 24, 2020 by an out of network (OON) provider.