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

We decided that the Plan does not have to waive the copayment for the laboratory work provided on January 28, 2020. 
 
You asked the Plan to waive the copayment for the laboratory work. You say that there is no copayment if lab tests are performed as a part of an office visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR testing (anti-coagulant testing). You will only pay one copayment per day even if multiple lab tests are performed.  
 
You have been asked to pay a $10 copayment for the laboratory work. The laboratory work 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 laboratory work provided on January 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat Zilretta injections (J3304). 
 
You asked the Plan to pre-approve repeat Zilretta injections. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is not intended for repeat administration. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.  
 
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 repeat Zilretta injections. Our reviewer says that the criteria for coverage of Zilretta has not been met. Our physician reviewer found repeat injections of Zilretta are experimental. They are not medically indicated 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 repeat Zilretta injections have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat Zilretta injections (J3304).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided from October 22, 2019 to October 23, 2019. 
 
You asked the Plan to pay for self-administered drugs. You say that you were not allowed to bring your own medications to the hospital, and this charge is twice the amount that you would normally pay for these drugs. The Plan denied your request. The Plan says the denial of payment for these drugs is correct, because these drugs are not covered by Medicare Part B. The Plan also says that you can request reimbursement for these drugs under your Medicare Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 pay for self-administered drugs provided from October 22, 2019 to October 23, 2019.  
 
Benefits for self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from January 18, 2020 through January 23, 2020 and the ambulance transport provided on January 27, 2020.
You asked the Plan to waive the copayment for the inpatient stay and ambulance transport. You say that the rehab should have the liability. You say that you shouldn't be responsible for the bills. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $175 copayment per day, days 1 to 7 at an in-network inpatient hospital and a $200 copayment per date of service regardless of the number of trips for emergency ambulance services. The enrollee has been asked to pay a total of $900 for the inpatient stay and ambulance transport.
Date of Service
Service
Standard Copayment
Member Liability
January 18, 2020 - January 23, 2020
Inpatient Stay
$175/day
$700
January 27, 2020
Ambulance Transport
$200
$200
TOTAL:
$900
The inpatient stay falls within the "Inpatient hospital care" benefit category. The ambulance transport falls within the "Ambulance services" 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 the inpatient stay provided from January 18, 2020 through January 23, 2020 and the ambulance transport provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse the coinsurance for DME supplies provided on December
23, 2019.
You asked the Plan to reimburse the coinsurance for DME supplies. You say that you paid $199 and disagree
with the amount you were reimbursed. 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 20%
coinsurance for DME and related supplies.
You received DME supplies on December 23, 2019. The allowed amount is $2.66 and 20% of that is $0.53.
Please contact the provider with any questions regarding overpayments or refunds.
You have been asked to pay the total coinsurance amount of $0.53 for DME supplies. DME supplies fall within
the 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 reimburse the coinsurance for DME
supplies provided on December 23, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided from July 30, 2019 to August 21, 2019. 
 
You asked the Plan to pay for the physical therapy services. You say that you had to keep up your physical therapy in Spain so that your joint could continue to grow strong. The Plan denied your request. The Plan says a referral was not obtained from your primary care physician. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.   
 
We looked at the file, and Medicare rules. The documentation in the case file does not show that the physical therapy services were urgent. The need for services was known prior to leaving the service area. The Plan did not pre-approve the services at issue. Based on this information, we decided that Medicare rules for coverage of have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided from July 30, 2019 to August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services you received on August 27, 2019. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment. 
 
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 per day for outpatient procedures and services.  
 
Review of the file shows that were provided outpatient services on August 27, 2019. You have been asked to pay a $50 copayment for the services. The services fall within the outpatient 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 services you received on August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair. 
 
You asked the Plan to pre-approve a lightweight wheelchair (K0003). You say that the enrollee needs a lightweight wheelchair. The Plan denied your request. The Plan says the criteria is not documented. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  
 
We looked at the file and Medicare rules. There is no documentation of the enrollee not being able to use a standard wheelchair or uses a lightweight wheelchair. There is no documentation of a home assessment. Based on this information, we decided that Medicare rules for coverage of a lightweight wheelchair (K0003) have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 11, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on December 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services provided on April 8, 2020. 
 
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that setup and operated the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. 
 
We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the perfusionist services provided on April 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger provided on February 4, 2020. 
 
You asked the Plan to pay for the perfusionist services (99190). You say that this equipment was provided to the enrollee during a surgery and should be covered. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services. 
 
The Plan must follow Medicare rules.  Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers.  
 
This equipment was used during a surgical procedure by the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital.  Based on this information, we decided that Medicare rules for coverage of the perfusionist services (99190) have not been met. Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger provided on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on April 8, 2020. 
 
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room through the duration of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on October 11, 2019.
You asked the Plan to pay for drug test. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this service is correct, because the documentation
submitted does not include a valid physician order, lab requisition, or medical records to support the service
billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided
that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing provided on October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on
December 11, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the
type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to
pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services provided on February 24, 2020. 
 
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that setup and operated the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says payment for services is the responsibility of the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. 
 
We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the perfusionist services provided on February 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee has a hard time finger stick testing. The Plan denied your request. The Plan says a CGM is not covered by Medicare when an enrollee is not on insulin. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  
 
We looked at the file and Medicare rules. The enrollee is not insulin treated so the Medicare coverage criteria for a CGM is not met. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed (E0265) and over the bed table (E0274).
You asked the Plan to pre-approve the hospital bed and table. You say that these items are needed for the enrollee as soon as possible because the enrollee really needs them. The Plan denied your request. The Plan says these items are not covered under Medicare or the plan.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed are not covered. Medicare rules state that over the bed tables are not covered because they are not primarily medical in nature. While the requested items may be appropriate in this case, neither the Plan nor Medicare offers coverage for these items. Therefore, we decided that the Plan does not have to pre-approve the total electric hospital bed (E0265) and over the bed table (E0274).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a negative pressure wound therapy electrical pump.
You asked the Plan to pre-approve continued use of a negative pressure wound therapy electrical pump. You say that the wound vac is necessary to avoid a hospital stay or surgery due to infection. The Plan denied your request. The Plan says according to the measurements submitted your wound has increased in size.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record shows wound healing has failed to occur over the month the device was used. Based on this information, we decided that Medicare rules for coverage of continued use of a negative pressure wound therapy electrical pump have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a negative pressure wound therapy electrical pump.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) provided on February 6, 2020.
You asked the Plan to pay for the dental services. You say that you called the Plan with your dentist to verify the dental coverage and you were told that you have coverage including x-rays and caps. The Plan denied your request. The Plan says when you enrolled in the 2020 plan year you did not choose to add the additional comprehensive dental services. The Plan states there are no calls documented in which you were advised that you had this coverage.
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. The services are not covered under Medicare or the Health Plan, because you did not choose to add the additional comprehensive dental services. Therefore, we decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) provided on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on February 6, 2020 and March 5, 2020 by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that the services rendered were due based on a urgent medical need. The Plan denied your request. The Plan says you do 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. 
 
Review of the file show that you received the dental services on February 6, 2020 and March 5, 2020 provided by an out-of-network provider. 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 dental services provided on February 6, 2020 and March 5, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the mechanical traction therapy (97012) provided on
January 2, 2020 and January 14, 2020.
You asked the Plan to pay for the mechanical traction therapy. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the mechanical traction therapy (97012) provided on January 2, 2020 and January 14, 2020.