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

We decided that the Plan does not have to pay for genetic testing provided February 5, 2021.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. We looked at the file and Medicare rules. The claim was billed with multiple unbundled codes. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided on March 29, 2021.
You asked the Plan to waive the copayment for wound care. You say that you are shocked by the charges and cannot afford them. 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 $295 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You have been asked to pay the allowed amount of $203.50, which is less than the $295 copayment for wound care. Wound care falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 wound care provided on March 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost-sharing charges for out-of-network outpatient mental health care.
You asked the Plan to reduce the cost-sharing charges for out-of-network outpatient mental health care. You say that you feel that the out-of-network provider will be the most helpful for your condition and request that future claims be processed at an in-network rate. The Plan denied your request. The Plan says there are in-network providers available to you, therefore, they will not adjust how they process future claims.
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 40% coinsurance for out-of-network outpatient mental health care. You have been asked to pay 40% coinsurance for out-of-network outpatient mental health care. Out-of-network outpatient mental health care falls within the outpatient mental health 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 reduce the cost-sharing charges for out-of-network outpatient mental health care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0299, G0151, & G0157) provided January 1, 2021 to January 17, 2021.

You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include the required elements for payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes G0299, G0151, & G0157 are not supported in the medical record. Specifically, the required "Q" code for the home health services was not included on the claim. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (G0299, G0151, & G0157) provided January 1, 2021 to January 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for vehicle modification provided on September 25, 2020.
You asked the Plan to reimburse you for the ramp threshold. You say that you were told the modifications were covered. The Plan denied your request. The Plan says the vehicle modifications do not meet the definition of DME as they are not for use in your home and they do not serve a primarily and customarily medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules state that for equipment to be covered, it must be appropriate and needed for use
inside the home. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to reimburse you for vehicle modification provided on September 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional six months of a continuous glucose monitor.
You asked the Plan to pre-approve the additional months. You say that this will greatly help you function. The Plan denied your request. The Plan says you need to see the physician every six months once starting on a continuous glucose monitor.
The Plan must follow Medicare rules. Medicare rules say that every six (6) months following the initial prescription of the continuous glucose monitor, the treating practitioner must have an in-person visit with the beneficiary to assess adherence to their monitor regimen and diabetes treatment plan. The plan has approved six months for this monitor. Any additional months beyond the approved six months cannot be approved until there is another in-person visit from the treating practitioner to assess the treatment plan. Based on this information, we decided that Medicare rules for coverage of the additional months have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional six months of a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81286, 81407, 81408, 81479) provided January 21, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is non-covered under Medicare.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular-respiratory disease We looked at the file and Medicare rules. The procedures at issue are a cardiovascular risk assessment panel and are non-covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81286, 81407, 81408, 81479) provided January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 22, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the member's primary care physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 lab work provided on January 22, 2020 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a non-plan provider.
You asked the Plan to pre-approve these services. You say that you are unable to go to an in-network provider.
The Plan denied your request. The Plan says the services are available from plan providers.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is
not providing these services and is not making arrangements to provide these services. Therefore, we decided
that the Plan does not have to pre-approve a referral to a non-plan provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gel pads and a seat belt.
You asked the Plan to pre-approve gel pads and a seat belt. You say that the items are necessary. The Plan denied your request. The Plan says the requested seat belt should be denied as unbundled. The gel pads are not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve gel pads and a seat belt.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for compression stockings provided to the enrollee on October 1, 2020.

You asked the Plan to pay for compression stockings. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the claim submitted has not physicians order, no proof of delivery and no medical records to show the enrollee met the required criteria for compression stockings.

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 rules also state specific criteria must be met for compression stockings to be covered. The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to pay for compression stockings provided to the enrollee on October 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $300 copayment charged for ambulance transport provided on February 16, 2021.
You asked the Plan to waive or reduce this copayment. You say that you think this copayment is too high. The Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement.
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 $300 copayment for each one-way ambulance transport. 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 or reduce the $300 copayment charged for ambulance transport provided on February 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on October 1, 2020.
You asked the Plan to pay for a neuromuscular stimulator. You say that the item at issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the item at issue is not medically necessary.
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 pay for a neuromuscular stimulator. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that a physical examination of the knees would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the neuromuscular stimulator was medically reasonable and necessary in this case, as there is insufficient documentation of a credible evaluation and physical examination of the enrollee's knees. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), a harness (E2313), attendant control (E2331), an electronic connection between wheelchair controller and two or more power seating system motors (E2311), and lemon crush accent color (K0108).
You asked the Plan to pre-approve an expandable controller, a harness, attendant control, an electronic connection between wheelchair controller and two or more power seating system motors, and lemon crush accent color. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that power wheelchair features and accessories are covered when specific criteria are met. 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 an expandable controller, a harness, attendant control, an electronic connection between wheelchair controller and two or more power seating system motors, and lemon crush accent color. Our reviewer says that the items are not medically necessary. Our physician reviewer found your function in the upper extremities with independence in feeding, grooming, upper body dressing supports that you can control any power options through their own individual switches. Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller, a harness, attendant control, an electronic connection between wheelchair controller and two or more power seating system motors, and lemon crush accent color have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), a harness (E2313), attendant control (E2331), an electronic connection between wheelchair controller and two or more power seating system motors (E2311), and lemon crush accent color (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable home ventilator.
You asked the Plan to pre-approve a portable home ventilator. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that ventilators (E0465, E0466) are covered for the specific conditions. 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 a portable home ventilator. Our reviewer says that the item is not medically necessary. Our physician reviewer found the review has determined that there is no evidence that the requested mechanical ventilator (E0466device) is indicated. You do not meet the coverage criteria detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out on network nursing services provided to the enrollee on January 11, 2021.

You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out on network nursing services provided to the enrollee on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 21, 2021.

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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the OncoCEE assay rendered on March 25, 2021.

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 testing is not covered.

The Plan must follow Medicare rules. The rules say that OncoCEE testing is denied as not medically necessary.

We looked at the file and Medicare rules. The test at issue is the OncoCEE assay. This test is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for the OncoCEE assay rendered on March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 12, 2021.

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 are not covered.

The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 9 represents a code for which the concept of a professional/technical component does not apply. 

We looked at the file and Medicare rules. Procedure codes 80048 and 85027 were billed with the -26 modifier for payment of the professional component. These codes have a status indicator of 9 and do not have a PC or TC component. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the $50 copayment charged for a diagnostic colonoscopy
provided on November 5, 2020.

You asked the Plan to waive this copayment. You say that this was a screening and should be no charge. The
Plan denied your request. The Plan says this copayment was charged based on the claim submitted by the
provider and the Plan contract agreement. The Plan states your provider did not submit medical records to
show this was a screening versus a diagnostic colonoscopy. Maximus overturned the Plans denial. The Plan
requested a reopen and restated that no medical records were submitted by the provider for review after
multiple attempts to retrieve them.

The Plan is correct 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 $50 copayment for outpatient diagnostic services. Your physician billed for
outpatient diagnostic services. You have been asked to 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 $50 copayment charged for a diagnostic colonoscopy provided
on November 5, 2020.
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 this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit and not considered medically necessary.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 A6530.