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

We decided that the Plan does not have to pay for the home infusion therapy, hydration therapy; more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (S9375) provided to the enrollee from January 18, 2020 to January 21, 2020.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that this is not valid for Medicare purposes.
The Plan must follow Medicare rules. The rules say that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. You are billing for home infusion services S9375. This is not a valid code for Medicare purposes and the plan does not offer an additional benefit for this service. Therefore, we decided that the Plan does not have to pay for the home infusion therapy, hydration therapy; more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (S9375) provided to the enrollee from January 18, 2020 to January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient alcohol treatment provided on November 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient alcohol treatment. You say that it shouldn't be your responsibility to figure out if a provider is in-network or out-of-network. The Plan denied your request. The Plan says no prior authorization was obtained.
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 outpatient alcohol treatment provided on November 8, 2019 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a federally qualified health center visit (G0468, G0439 and G9226) provided on November 26, 2019.
You asked the Plan to pay for the federally qualified health center visit. You say that you would like reconsideration because these services have been coded correctly. The Plan denied your request. The Plan says per Medicare guidelines, this service is not billable to the fiscal intermediary.
The Plan must follow Medicare rules. Medicare rules say that services with Status Indicator = M are not billable to the MAC and are subject to edit 72. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the federally qualified health center visit have not been met. Specifically, CPT code G9226 has a status indicator of M which means that it is not billable to the MAC. Additionally, CPT code G9226 is not eligible for the FQHC bypass. Therefore, we decided that the Plan does not have to pay for a federally qualified health center visit (G0468, G0439 and G9226) provided on November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0651, E0673).
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0651, E0673).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on January 7, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you paid less last year for the same ultrasound. You say you were told that Medicare will not allow payment for the ultrasound this year. 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 a $155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $155 copayment for the ultrasound.
You have been asked to pay a $123.44 copayment for the ultrasound. The ultrasound falls within the each "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 ultrasound provided on January 7, 2020.
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on January 14, 2020 to January 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for acupuncture services. You say that you verified you were in-network prior to these services. The Plan denied your request. The Plan says no prior authorization was obtained.
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 acupuncture services provided on January 14, 2020 to January 28, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bifocal lenses purchased January 15, 2020.
You asked the Plan to pay for the vision services. You say that you did not order your lenses by December 31, 2019 because you were ill. You feel that 1 set of lenses should go toward benefit year 2019. You have 2 different sets because 1 is for computer use. The Plan denied your request. The Plan says this request exceeds the benefit limit as the maximum allowance has been paid for date of service January 14, 2020.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan eyewear coverage is limited to 1 set of frames and 1 set of lenses or contact lenses per calendar year. We looked at the file and the Plan's rules. Eyewear coverage is limited to 1 set of frames and 1 set of lenses or contact lenses per calendar year. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the bifocal lenses purchased January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the initial periapical x-ray (D0220) and the prophylaxis (D1110) provided on December 23, 2019.
You asked the Plan to reimburse you for the dental services. You say that you are covered for 2 cleanings per year. You say that you received your second of the year as well as your 1 set of yearly x-rays that are covered. You also say that you received the services before your coverage ended. The Plan denied your request. The Plan says the periapical x-ray is not a covered service. The Plan says that 1 prophylaxis is covered per year. The Plan also says that the frequency limit for prophylaxis has been exceeded.
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 and prophylaxis is a covered service, the frequency limit of once every year has been exceeded. The record shows that you last received prophylaxis on June 19, 2019. Additionally, periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the initial periapical x-ray (D0220) and the prophylaxis (D1110) provided on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on January 22, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 you by an out-of-network provider on January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 9, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
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) located in 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 an in-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 for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 16, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 11, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says documentation submitted did not include a Proof of Delivery, or a 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 physician order and 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. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 11, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing.
You asked the Plan to pre-approve genetic tests. You say that biomarker expression is a critical component of cancer care and instrumental in decoding cancer to better understand the biology driving tumor growth. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because there is not good medical evidence that shows doing the large number of tests in a profile is helpful for management of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pre-approve genetic tests. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found testing specifically related to the enrollee's condition would be medically necessary, however panel testing inclusive of testing that is not related to the enrollee's condition or for which there are no associated therapies is not medically reasonable or 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 genetic tests have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a sacral wound. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on December 18, 2019.You asked the Plan to waive the coinsurance for the Part B injection. You say that you were told the injection would be 100% covered and you would only have a $35 copayment for the visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the allowed amount for in-network Medicare Part B-covered drugs. You have been asked to pay $162.36 which is 20% of the allowed amount for the Part B injection. The allowed amount is $811.80. ($811.80 x 20% = $162.36). The Part B injection falls within the of "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B injection provided on December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a follow-up office visit provided on January 22, 2020 by an out of network (OON) provider.You asked the Plan to pay fora follow-up office visit. You say that there was a mistake and you ended up seeing a different doctor.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available 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 fora follow-up office visit provided on January 22, 2020 by an out of network (OON)provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code E1399.You asked the Plan to pre-approvethe compression stockings. You say that the claim should be paid.The Plan denied your request. The Plan says support stockings are not used to take care of medical need.The Plan must follow Medicare rules. The rules say that compression stockings described by code E1399 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code E1399
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lenses and fitting provided on December 17, 2019.You asked the Plan to pay for the services provided. You say that the fitting and lenses are necessary to treat your medical condition.The Plan denied your request. The Plan says the contact lenses and fitting are not a covered benefit of your plan.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear.The services are not covered by Medicare or your plan. Therefore, we decided that the Plan does not have to pay for the contact lenses and fitting provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on September 24, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because this was your annual physical. 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 $20 copayment for each visit to a primary care provider. The record shows that you had an office visit on September 24, 2019. The claim was submitted with diagnostic codes. Therefore, services beyond an annual wellness visit took place and you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on September 24, 2019.