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

We decided that the Plan does not have to pay for the glucose blood reagen provided on November 20, 2020 by an out of network (OON) provider.


You asked the Plan to pay for the glucose blood reagen. 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.

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 had network providers available who could have provided 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 glucose blood reagen provided on November 20, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine venipuncture, CT of the head/brain, chest x-ray, CT of the neck spine, hip x-ray, knee x-ray, comprehensive metabolic panel, urinalysis, complete blood cell count, prothrombin time, PTT, bacterial culture for aerobic isolates, urine culture, evaluation of antimicrobial drug, diphtheria and tetanus vaccine, ECG, and ED visit provided on October 16, 2020.
You asked the Plan to pay for the laboratory services, CT scans, x-rays, evaluations, cultures, and ED visit. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the routine venipuncture, CT of the head/brain, chest x-ray, CT of the neck spine, hip x-ray, knee x-ray, comprehensive metabolic panel, urinalysis, complete blood cell count, prothrombin time, PTT, bacterial culture for aerobic isolates, urine culture, evaluation of antimicrobial drug, diphtheria and tetanus vaccine, ECG, and ED visit provided on October 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20 hours per week of personal care and homemaker services.
You asked the Plan to pre-approve the homemaker services. You say that you need assistance with activities of daily living. The Plan denied your request. The Plan says Medicare only covers home health aides when a person requires in-home skilled nursing care from a Medicare certified Home Health Agency.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the homemaker services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 20 hours per week of personal care and homemaker services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for closure of lacrimal punctum, by plug, each (68761) provided September 28, 2020.

You asked the Plan to waive the copayment for the vision services. You say that you are asking the plan to review and hopefully correct the billing for your visits after having eye surgery as you were told these visits were still part of post operation and additional copay was not due. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.

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 $35 copay for each covered exam to diagnose and treat diseases and conditions of the eye. 

You have been asked to pay $35 copay for the vision services. The vision services fall within the Vision 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 closure of lacrimal punctum, by plug, each (68761) provided September 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested services are medically
necessary. The Plan denied your request. The Plan says rules for the LTACH services have not been met.
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 has a past medical history of diabetes, end stage renal disease, and
heart failure who presented to an acute hospital on January 27, 2021, with encephalopathy. The enrollee was
treated in the hospital and then was transferred to a skilled nursing facility. The skilled nursing facility can
provide for all of the enrollee's present inpatient care needs and the enrollee is receiving an appropriate level of
care in the present setting. The Plan has stated that continued care in the skilled nursing facility will be covered.
Continued care in the skilled nursing facility is appropriate unless the enrollee's condition changes and requires
acute hospital level care.
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 the LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on June 13, 2020.
You asked the Plan to waive the copayment for the ambulance ride. You say that you were never informed you would need prior authorization for the ambulance transfer. The Plan denied your request. The Plan says decided to cover the ambulance ride and the claim has been reprocessed. You have been asked to pay 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 $250 copayment for Medicare-covered ambulance services. Cost sharing applies for each one-way trip. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $250 copayment for the ambulance ride.
You have been asked to pay a $247.22 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" 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 ambulance ride provided on June 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient surgery services provided on December 8, 2020.
You asked the Plan to waive the copay for the services provided. You say that the surgeon's office told you that you got a discount. The Plan denied your request. The Plan says the copay was applied based on your benefits.
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 copay for surgical services in an outpatient hospital facility. You have been asked to pay a $325 copay for the services provided. The services fall within the outpatient surgery 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 copay for the outpatient surgery services provided on December 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869).
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the enrollee needs the device for back pain relief. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.
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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcutaneous epidural nerve stimulation (TENS) unit
to be provided by an OON provider.
You asked the Plan to pre-approve TENS unit. You say that some in-network providers did not have the needed
item or would not submit a claim. The Plan denied your request. The Plan says the denial of authorization for
this item is correct, because this provider is out-of-network with the Plan, and you can receive this item from an
in-network durable medical equipment supplier.
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 care that cannot be provided by network providers.
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
transcutaneous epidural nerve stimulation (TENS) unit to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided on June 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for practitioner visit. You say that your provider depends on the facility staff to verify eligibility and obtain authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 had network providers available who could have provided 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 a practitioner visit provided on June 23, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vitamin D Assay testing with code 82306 provided on August 27, 2020.
You asked the Plan to pay for the Vitamin D Assay testing. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the Vitamin D Assay testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Vitamin D Assay testing with code 82306 provided on August 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an out-of-network (OON) endodontist.
You asked the Plan to pre-approve the office visit. You say that you would like to see this OON provider because your dentist recommended them. The Plan denied your request. The Plan says you would like this service to be rendered OON. The Plan also says that there are 7 participating endodontic providers within 20 miles of your zip code.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve an office visit with an out-of-network (OON) endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740), core buildup, including any pins when required (D2950), and gingivectomy or gingivoplasty (D4212) provided on December 17, 2020.
You asked the Plan to pay for the crown, core buildup, and gingivectomy or gingivoplasty. You say that you were advised that the extraction would be paid for and the crown would be partially paid. The Plan denied your request. The Plan says these services are not covered.
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 crown (D2740), core buildup, including any pins when required (D2950), and gingivectomy or gingivoplasty (D4212) provided on December 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the shoulder elbow wrist hand orthosis (L3960) provided November 18, 2020.
You asked the Plan to waive the coinsurance for the shoulder elbow wrist hand orthosis. You say that you believe this item should be included in the surgery claim. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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 durable medical equipment. You have been asked to pay a total cost share of $147.67 for the shoulder elbow wrist hand orthosis ($738.37 allowed amount x 20% coinsurance). The shoulder elbow wrist hand orthosis falls within the durable medical equipment benefit category. It does not fall within the surgery claim because you received it upon discharge. 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 shoulder elbow wrist hand orthosis (L3960) provided November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Life Alert device (A9280).
You asked the Plan to pre-approve Life Alert device. You say that this item is medically necessary for the enrollee's high risk of a fall. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that emergency communications systems are not covered because they do not serve a diagnostic or therapeutic purpose. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Life Alert device have not been met. Therefore, we decided that the Plan does not have to pre-approve Life Alert device (A9280).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe basic life support ambulance services coded A0429 provided on July 11, 2020.

You asked the Plan to pay forthe basic life support ambulance services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary]. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances.Therefore, we decided that the Plan does not have to pay forthe basic life support ambulance services coded A0429 provided on July 11, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you were told you would be allowed skilled care
again. The Plan denied your request. The Plan says the denial of SNF care is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled
Nursing Facility (SNF) setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.
You asked the Plan to pre-approve the requested device. You say that the enrollee has failed 6 months of conservative approaches. The Plan denied your request. The Plan says experimental procedure are not covered by Medicare.
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 the requested device. Our physician reviewer found that the requested device is experimental and investigational. More research is needed to show its safety and efficacy. Therefore, the requested device is not considered medically reasonable or necessary at this time. 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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device.