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

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.You asked the Plan to pre-approve Freestyle Libre. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee is not checking blood sugar at least 4 times per day, is on injectable insulin only once per day, and refused to start taking insulin with meals.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.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 Freestyle Libre. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested continuous glucose monitor. Our physician reviewer found the enrollee is not taking 3 to 4 shots of insulin per day and not testing 4 or more times per day. This does not mean the continuous glucose monitor would not help the enrollee, however it is not covered by Medicare under these circumstances.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of FreestyleLibre have not been met.Therefore, we decided that the Plan does not have to pre-approvea Freestyle Libre continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 8, 2019 by an out of network provider.  You asked the Plan to pay for the scheduled non-emergent ambulance transport. You say that the transport was medically necessary. The Plan denied your request. The Plan says you did not have prior authorization for the transport.
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 service 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 ambulance services provided on March 8, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 8, 2019 by the out of network provider.
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is also not in-network. The Plan says that the providers primary care physician did not refer 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 the medical services provided on July 8, 2019 by the out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services (G0162) provided on February 27, 2019.You asked the Plan to pay forthe home health 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 providers must report services correctly. We looked at the file and Medicare rules. Home health care services must be billed on a UB-04 form per Medicare guidelines. The case file shows the home health services were submitted on a CMS-1500 form incorrectly.Therefore,we decided that the Plan does not have to pay forthe home health services (G0162) provided on February 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy rendered to you on August 27, 2019.You asked the Plan to waive the copayment for these services. You say that the colonoscopy should be covered in full.The Plan denied your request. The Plan says the copayment was 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 $325 copayment for outpatient surgery at an outpatient hospital facility. Review of the file shows that you had a diagnostic colonoscopy on August 27, 2019. The colonoscopy was diagnostic and not screening in nature because it resulted in biopsies and polyp removal. You have been asked to pay a $325 copayment for these services. These services fall within the outpatient surgery at an outpatient hospital facility 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 forthe diagnostic colonoscopy rendered to you on August 27, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on September 3, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that you tried to go to urgent care but were referred to the emergency room. You say that you only went because you were referred. 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 $110 for each Medicare-covered emergency room visit. You have been asked to pay a $110 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you received services in the ED. 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 ED visit provided on September 3, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to waive the copayment for the ambulatory surgical center and coinsurance for the monovisc injection provided on May 28, 2019
You asked the Plan to waive the copayment for the ambulatory surgical center and coinsurance for the monovisc injection. You say that you should only have a $45 copay like in the past. The Plan denied your request. The Plan says that that the claims processed correctly.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not forwarded there 2019 Evidence of Coverage. Without the Evidence of Coverage we are unable to confirm the cost-sharing amounts were charged correctly. Therefore, we decided that the Plan has to waive the copayment for the ambulatory surgical center and coinsurance for the monovisc injection provided on May 28, 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 pay for physician's services provided on June 5, 2019.
You asked the Plan to pay for the physician's 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 is not a network provider with the Plan. The Plan did not pre-approve the service 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 June 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0480 and 80307 provided on May 6, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 G0480 and 80307 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0480 and 80307 provided on May 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on June 24, 2019 by an out of network provider.
You asked the Plan to pay for subsequent nursing facility care. You say that you are not the custodian of records and you provided medically necessary services to the Plan's member in good faith. The Plan denied your request. The Plan says services from non-participating providers are not covered under the plan unless they are authorized before the services are provided.
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 subsequent nursing facility care (99308) provided on June 24, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor provided on July 22, 2019.
You asked the Plan to pay for the glucose monitor. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor provided on July 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on September 12, 2019.
You asked the Plan to pay for the endodontic therapy. You say that you had an infection in the bone of your skull located at the root of a tooth. You also say that you feel that this service should be covered under your plan because it was an infection that needed surgery. The Plan denied your request. The Plan says this service is not a covered benefit under Medicare and your 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 endodontic therapy provided on September 12, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by the Hospital on August 25, 2019.
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not recall why you went to the emergency department however, because you are low income it would have to be something serious. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit was provided, the correct copayment has been applied. An 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 an emergency room visit provided by theHospital on August 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit on September 19, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you were told you would not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for each specialist visit. You have been asked to pay a $25 copayment for a specialist visit. A specialist 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 a specialist visit on September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a gym membership for the 2017 and 2018 benefit year.
You asked the Plan to reimburse you for the gym membership. You say that you did not realize that there was a cutoff date to submit the request for reimbursement to the Plan. The Plan denied your request. The Plan says you submitted for reimbursement for your 2017 and 2018 Wellness Allowance after the March 31st deadline for both years.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because you submitted for reimbursement for your 2017 and 2018 Wellness Allowance after the March 31st deadline for both years. Therefore, we decided that the Plan does not have to reimburse you for a gym membership for the 2017 and 2018 benefit year.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing panels provided on April 11, 2019.
You asked the Plan to pay for the drug panels. You say that this testing was medically necessary and should be paid. The Plan denied your request. The Plan says the POS code reported is not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that the POS code for lab claims must reflect the location in which the sample was taken. In this case, the documentation shows that the sample was taken at the office and not at the lab itself. As such, the POS code 81 is not supported. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing panels provided on April 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from August 5, 2019 to August 12, 2019.
You asked the Plan to pay for the HIT services. You say that this code is valid according to the CMS website and must be paid. The Plan denied your request. The Plan says this code is not valid for Medicare billing.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code S9328 has a status indicator of "I" meaning it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from August 5, 2019 to August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution and lancet device provided by "the provider" from May 23, 2019 to August 11, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256) and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physicianorder and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution and lancet device provided by "the provider" from May 23, 2019 to August 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthoses and the shoulder elbow wrist hand orthoses provided on November 5, 2018.You asked the Plan to pay forthe knee orthoses and the shoulder elbow wrist hand orthoses. 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.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) locatedin a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for anin-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe knee orthoses and the shoulder elbow wrist hand orthoses provided onNovember 5, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (99205, 99245, 52000, 99213, 88325,
88321, 88323) to be provided by the out of network provider.
You asked the Plan to pre-approve a consultation. You say that you are appealing your out of network
consultation for a second opinion. You say you are not comfortable with the treatment plan from the innetwork
provider. You further say you would like a second opinion to confirm what the in-network provider
stated is correct. The Plan denied your request. The Plan says the provider is not in the network. The Plan says
per your EOC, there is no benefit for out-of-network coverage unless the services are urgent or cannot be
provided in-network, or it's an emergency. The Plan further says they found two in-network
providers, that can provide the requested 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a consultation (99205, 99245, 52000, 99213, 88325, 88321, 88323) to be provided by the out of network provider.