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

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on September 16, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no Delivery Ticket and the Proof of Delivery did not include details to corroborate what was delivered.
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. There is no Delivery Ticket 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 knee orthoses and suspension sleeves provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services provided to the enrollee on October 16, 2018.
You asked the Plan to pre-approve the services. You say that this provider is a Medicare provider. The Plan denied your request. The Plan says the enrollee has no out-of-network benefits.
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 ophthalmology services provided to the enrollee on October 16, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the
enrollee on August 30, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says they were unable to discover any evidence of an established
relationship between the member and the ordering physician. The Plan states there were no claims submitted
for an evaluation and management service. The Plan states the review of claims history for this member, and a
review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service
with the ordering physician as required per CMS guidelines.
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 orthosis. Our reviewer says that the
enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the documentation in the
case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for
the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately
assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not
support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is no
documentation of a credible physical examination of the shoulder.
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 orthosis have not been met. Therefore, we decided that the Plan does not
have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on June 5, 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 procedure codes 37241 and 36012 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 37241 is venous embolization for acquired venous malformation, with imaging guidance. The definition of code 36012 is selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal vein, petrosal sinus). We find that CPT codes 37241 and 36012 are not supported in the medical record. Specifically, the operative report does not contain documentation of vascular embolization or occlusion to support code 37241 or selective catheter placement for code 36012. 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 services rendered to the enrollee on June 5, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (99213) provided on August 20, 2019 by the out of network provider.
You asked the Plan to pay for the outpatient mental health services. You say that the services should be covered. The Plan denied your request. The Plan says the services were provided out-of-network. They were not emergent or preauthorized. The plan has providers in-network that could provide the services at issue.
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 outpatient mental health services (99213) provided on August 20, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the cardiac catheterization procedure provided from July 5, 2019 to July 6, 2019.
You asked the Plan to reduce the coinsurance for the cardiac catheterization procedure. You say that you should be charged the inpatient copayment for the surgery. 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 20% coinsurance for all other services for outpatient hospital services (including observation). You have been asked to pay $2,129.55 which is 20% for the cardiac catheterization procedure. The allowed amount is $10,647.74. ($10,647.74 x 20% = $2,129.55). The cardiac catheterization procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows you were considered an outpatient.
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 reduce the coinsurance for the cardiac catheterization procedure provided from July 5, 2019 to July 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Losartan Potassium 100mg tab.
You asked the Plan to pre-approve Losartan Potassium 100mg tab. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 pre-approve Losartan Potassium 100mg tab.
Benefits for Losartan Potassium 100mg tab may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periapical x-ray (D0220), the surgical extraction (D7210), the consultation (D9310), the bone replacement graft (D7953), and the guided tissue regeneration (D4266) provided from June 11, 2019 to June 23, 2019.
You asked the Plan to reimburse you for the dental services. You say that you had no choice for this surgery. You say that the bone would continue to deteriorate without the surgery. You also say that the services were not a cosmetic choice. The Plan denied your request. The Plan says the dental services you received are not covered services.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the periapical x-ray (D0220), the surgical extraction (D7210), the consultation (D9310), the bone replacement graft (D7953), and the guided tissue regeneration (D4266) provided from June 11, 2019 to June 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 49568) provided to the enrollee on June 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service cannot be reimbursed separately.
The Plan must follow Medicare rules. Medicare rules say that add-on codes can only be reported in addition to a primary procedure. The billed primary procedure was denied in this case. As the primary procedure cannot be paid, the add-on code is also ineligible for payment. Therefore, we decided that the Plan does not have to pay for the services (CPT 49568) provided to the enrollee on June 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) provided on September 11, 2019.
You asked the Plan to pay for the dental service. You say that this service was pre-approved by the Plan. The Plan denied your request. The Plan says the cone beam CT is not a covered service.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) provided on September 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on August 30, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that the service was approved for payment. You say that you were not informed of a copayment. 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 a $225 copayment for each Medicare-covered advanced imaging service from an in-network provider. You have been asked to pay a $225 copayment for the CT scan. The CT scan falls 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 CT scan provided on August 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance transportation to your medical appointments.
You asked the Plan to pre-approve ambulance transportation. You say that you need transportation to your
cancer treatments. The Plan denied your request. The Plan says Medicare does not cover ambulance
transportation to a physician's office.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination.
The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pre-approve ambulance transportation to your medical
appointments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mental status evaluation provided on May 9, 2019 to July 10, 2019 by the out of network provider.
You asked the Plan to pay for mental status evaluation. You say that the member resides at the facility. You say that no other treatment options are available for these patients. 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 mental status evaluation provided on May 9, 2019 to July 10, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on August 21, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you were released from the hospital too early and had to return to the emergency room. You say that the Plan should be responsible for the copayment. 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 a $225 copayment for each Medicare-covered advanced imaging service from an in-network provider. You have been asked to pay a $225 copayment for the CT scan. The CT scan falls 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 CT scan provided on August 21, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on August 7, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that the provider's office contacted
emergency services. You say that you would not have contacted them. 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 a $90
copayment for each emergency room visit.
You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care"
benefit category. The records show that you were treated 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 August 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the abutment supported porcelain crown (D6058) for tooth # 9 provided on March 6, 2019.
You asked the Plan to pay for the dental service. You say that the service was medically necessary. You also say that the service should be covered as any other broken bone would be. The Plan denied your request. The Plan says dental implants are not a covered service.
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 abutment supported porcelain crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the abutment supported porcelain crown (D6058) for tooth # 9 provided on March 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity 0.75mg/0.5 ml pen.
You asked the Plan to pre-approve Trulicity 0.75mg/0.5 ml pen. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 pre-approve Trulicity 0.75mg/0.5 ml pen.
Benefits for Trulicity 0.75mg/0.5 ml pen may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided to the enrollee on
September 9, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says they were unable to discover any evidence of an established
relationship between the member and the ordering physician. The Plan states there were no claims submitted
for an evaluation and management service. The Plan states the review of claims history for this member, and a
review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service
with the ordering physician as required per CMS guidelines.
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 orthosis. Our reviewer says that the
enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the documentation in the
case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the
enrollee in this case. An appropriate history and a physical examination of the wrist and hand would reasonably
be required to adequately assess whether the wrist/hand orthosis was medically reasonable and necessary. The
documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this
case, as there is no documentation of a credible physical examination of the wrist.
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 orthosis have not been met. Therefore, we decided that the Plan does not
have to pay for wrist hand orthosis (L3916) provided to the enrollee on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and duplex scan provided on
July 17, 2019 and July 30, 2019.
You asked the Plan to waive the copayment for the office visit and duplex scan. You say that the doctor
informed you nothing could be done. You say that the doctor had no intention of doing anything for you. 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 $40
copayment for each specialist visit for Medicare-covered benefits and a $25 copayment for a Medicare-covered
ultrasound.
You have been asked to pay a $40 copayment for the office visit and a $25 copayment for the duplex scan. The
office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category.
The duplex scan falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit
category. The records show that the office visit and duplex scan were provided.
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 office visit and duplex scan provided on July 17, 2019
and July 30, 2019.
Your complaint about fraud and wasting Medicare funding 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.