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

We decided that the Plan does not have to waive the copayment for a colonoscopy with biopsy (45380) provided on June 18, 2019.
You asked the Plan to waive the copayment for a colonoscopy with biopsy. You say that this should have been processed as a preventative colonoscopy. The Plan denied your request. The Plan says this processed 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 $300 copayment for surgery at a freestanding Ambulatory Surgical Center. You contract also states that if you also are treated or monitored for an existing medical condition during the visit when you receive the preventive service, a copayment will apply for the care received. You have been asked to pay a $300 copayment for a colonoscopy with biopsy. The record shows that a polyp was removed and biopsied during this procedure, meaning it was no longer a preventative service. 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 colonoscopy with biopsy (45380) provided on June 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328).
You asked the Plan to pay for home infusion therapy. You say that this should be paid. The Plan denied your request. The Plan says this code is not recognized by Medicare.
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 code S9328 is not supported in the medical record. Specifically is code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a walker provided on
July 23, 2019.
You asked the Plan to waive the deductible for a walker. You say that you confirmed that the provider is in-network.
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. Your
contract with the Plan says that there is a $1,500 deductible for out-of-network durable medical equipment and
related supplies.
You received a walker from an out-of-network provider on July 23, 2019. Therefore, you are responsible to pay
your share of the out-of-network cost-sharing charges. The record shows that you had paid $0 toward the
$1,500 deductible. Therefore, you are responsible to pay the allowed amount of $45.83.
The item or service you asked the Plan to waive the deductible for falls within the benefit category durable
medical equipment and related supplies. The Plan has followed Medicare rules by clearly disclosing in the
contract that there is a $1,500 deductible for durable medical equipment and related supplies. This cost sharing
is a contractual obligation that had not been met at the time a walker was received on July 23, 2019. Therefore,
we decided that the Plan does not have to waive the deductible for a walker provided on
July 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided on April 24, 2019.
You asked the Plan to waive the deductible for laboratory services. You say that you disagree with the charges. 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. Your contract with the Plan says that there is a $250 deductible for outpatient diagnostic tests and therapeutic services and supplies. The record shows that you received laboratory services on April 24, 2019. You had paid $0 toward the $250 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $194.06. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory services were received on April 24, 2019. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on April 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on September 24,
2018 through September 25, 2018.
You asked the Plan to pay for the subsequent hospital care. You say that you did not receive proper notice of
the member's benefit determination. The Plan denied your request. The Plan says the documents submitted are
not considered good cause of why the claims were submitted untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the subsequent hospital care was not filed until September 27, 2019. This
means that more than one calendar year from the date of service had passed before a claim was filed.
Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99233) provided on
September 24, 2018 through September 25, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the BiPAP provided from February 16, 2019 to September 6, 2019.
You asked the Plan to waive the coinsurance for the BiPAP. You say that the provider should be paid for this since your previous provider already paid for twelve months of rental. The Plan denied your request. The Plan says that the claims processed 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 20% coinsurance for Durable medical equipment (DME) and related supplies. You have been asked to pay 20% coinsurance for the BiPAP. The BiPAP falls within the Durable medical equipment (DME) and related 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 coinsurance for the BiPAP provided from February 16, 2019 to September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 14, 2019 to February 28, 2019 by out of network provider.
You asked the Plan to pay for physician services. You say that these services were medically necessary and would like this claim reprocessed for payment. 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 the medical services provided on February 14, 2019 to February 28, 2019 by 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 June 24, 2019 by out of network provider.
You asked the Plan to pay for the medical services. You say that these services were provided while the enrollee was staying at a nursing home. The provider relies on the facility to obtain all necessary authorizations. This should be covered due to medical necessity. The Plan denied your request. The Plan says the enrollee is a resident at the non-contract facility receiving custodial care. There was no referral from a network provider and the treating provider failed to obtain authorization prior to furnishing this non-emergency 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 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 June 24, 2019 by out of network provider.
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 July 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 the enrollee has previously received the same supplies within the 5-year RUL.
The plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment on May 2, 2018. This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue. 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 a lumbar-sacral orthosis (L0650) provided to the enrollee on July 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 alveoloplasties in conjunction with extractions and 7 extractions provided on March 7, 2017.


You asked the Plan to pay for the alveoloplasties and extractions. You say that you are receiving phone calls from a company called Radius Global Solutions, a collection agency, about the money you owe. You also say that the Plan told you that you are not responsible for the bill.  The Plan denied your request. The Plan says you were charged a $35 copayment for each extraction and a $30 copayment for each alveoloplasty which totals a $305 enrollee liability. The Plan also says that the copays were applied appropriately.

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 contract says that you are responsible for a $10 - $75 copayment for Periodontics and Extractions. The record shows that you must pay a $35 copayment for each extraction and a $30 copayment for each alveoloplasty. Therefore, we decided that the Plan does not have to pay for the 2 alveoloplasties in conjunction with extractions and 7 extractions provided on March 7, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on March 21, 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 support the diagnosis used on the submitted order, nor did the documentation indicate the provider discussed the need for the billed supply code.
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 physician order for the supplies provided in this case. The documentation does not support that the physician order information includes pertinent information including, but not limited to, duration of the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc for the wrist-hand orthosis. Since the physician order does not reference this it is not valid. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on March 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from September 26, 2018 to March 20, 2019.
You asked the Plan to pay for home infusion therapy. You say that this service was medically necessary. The Plan denied your request. The Plan says the submitted code is not payable by Medicare.
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 code S9328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from September 26, 2018 to March 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the leg joint (73721) provided on June 20, 2019.
You asked the Plan to waive the copayment for the MRI of the leg joint. You say that the enrollee should not be responsible for such a large copayment. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $205 copayment for diagnostic radiology other than CT scans. The enrollee has been asked to pay $205 for the MRI of the leg joint. An MRI of the leg joint falls within the diagnostic radiology other than CT scans benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the leg joint (73721) provided on June 20, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from July
29, 2019.
You asked the Plan to pay for home health services. You say that this should be paid. The Plan denied your
request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim
does not contain a valid Treatment Authorization Code or a Q code to report the location where services were
provided. Therefore, we decided that the Plan does not have to pay for the home health services provided to the
enrollee from July 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 12, 2018 by out of network provider.
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 services were rendered by a non-participating provider without 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 referring provider 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 laboratory services provided on December 12, 2018 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you need the compression stockings to improve circulation. You have varicose veins and spider veins. The Plan denied your request. The Plan says gradient compression stockings A6530 are non-covered when there is no qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management
services (99239) provided on May 2, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted
discharge summary does not support hospital discharge day management of more than 30 minutes was
performed.
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 99239 is hospital discharge day management; more than
30 minutes.
We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not indicate
that more than 30 minutes of hospital discharge day management services were rendered. Based on this
information, we decided that Medicare rules for coverage of the hospital discharge day management services
have not been met. Therefore, we decided that the Plan does not have to pay for more than 30 minutes of
hospital discharge day management services (99239) provided on May 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medicaly necessary. The Plan denied your request. The Plan says this is not covered by Medicare for this condition.
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 the monitor. Our reviewer says that the requested monitor is not medically reasonable and necessary. Our physician reviewer found the provided medical records do not indicate that the Freestyle Libre therapeutic continuous glucose monitor is medically reasonable and necessary for the enrollee - the enrollee is not on insulin. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 9, 2019 by out of network provider.
You asked the Plan to pay for the medical services. You say that since the member was in the nursing facility, the doctor was not responsible to get authorization. The Plan denied your request. The Plan says the member does not have 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The services are not authorized because the doctor is a non-network provider who does not work with the member's health plan and the member was referred by his non-participating nursing home. The member's primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. There is no network deficiency for these services and alternate network providers were found. There is an on-line Medicare site to verify eligibility. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 9, 2019 by out of network provider.