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

We decided that the Plan does not have to pay foran X-ray of the Shoulder (73020) provided August 17, 2019.You asked the Plan to pay forThe X-ray. You say that the service was medically necessary.The Plan denied your request. The Plan says the code at issue shares a Column I / Column II relationship with a code already paid.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, we have confirmed that code 73020 has a bundled relationship with code 73030 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay foran X-ray of the Shoulder (73020) provided August 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Z1 Auto Travel CPAP machine and
accessories provided on February 20, 2019 by an out of network provider.
You asked the Plan to reimburse you for the Z1 Auto Travel CPAP machine and accessories. You say that you
were approved and elected to immediately purchase the items. The Plan denied your request. The Plan says
the provider is not a contracted provider and you ordered the equipment before the authorized date.
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 reimburse you 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 at issue in this appeal. The Plan did not pre-approve the items at issue for
purchase from an out-of-network provider. We found no exception that would require the Plan to reimburse
you for these items. Therefore, we decided that the Plan does not have to reimburse you for the Z1 Auto Travel
CPAP machine and accessories provided on February 20, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe comprehensive oral evaluation (D0150), the panoramic x-rays (D0330), and the complete series of intraoral x-rays (D0210) provided from September 3, 2019 to September20, 2019 by an out of network provider.You asked the Plan to reimburse you forthe dental services. You say that your plan has reimbursed you for previous services that you received from non-contracted providers. you say that you have not been able to locate an in network dental provider. You say that the provider in this case is much cheaper than the plan's network dentists. You also say that you have been requesting a provider directory since October and have yet to receive one from anyone except your case manager.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says panoramic x-rays are limited to coverage once every 3 years. The Plan also confirmed that they previously paid for services that you received from this provider and advised that going forward you need to use contracted provider for covered services.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 dental services were received out of network. The Plan requires you to use contracted providers for covered services as you were previously advised.Therefore, we decided that the Plan does not have to reimburse you forthe comprehensive oral evaluation (D0150), the panoramic x-rays (D0330), and the complete series of intraoral x-rays (D0210) provided from September 3, 2019 to September 20, 2019 by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided in Mexico from February 6, 2019 to June 26, 2019.You asked the Plan to pay for medical services provided in Mexico. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were not urgent or emergent.Medicare rules say that with limited exceptions, items and services furnished outside the United States are excluded from coverage, however, the Plan covers emergent and urgent services worldwide. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due. We looked at the file and Medicare rules. The submitted documentation does not show that the services at issue were urgent or emergent. Medical records were not submitted for all the dates of service at issue. Without this information, it cannot be established that the Plan's criteria for coverage have been met. Based on this information, we decided that Medicare rules for coverage of medical services provided in Mexico have not been met.Therefore, we decided that the Plan does not have to pay for medical services provided in Mexico from February 6, 2019 to June26, 2019.
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 December 6, 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; therefore the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit with an out-of-network provider on November 20, 2019.You asked the Plan to waive the deductible for an office visit. You say that you disagree with the out-of-network charges because the provider is the only one that you can see.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 physician/practitioner services, including doctor's office visits. You received an office visit with an out-of-network provider on November 20, 2019. The record shows that you had paid $0 toward the $1,500 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $171.88. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 deductible for out-of-network physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on November 20, 2019.Therefore, we decided that the Plan does not have to waive the deductible for an office visit with an out-of-network provider on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring system.You asked the Plan to pre-approve a CGM. You say that you need a CGM because you have decreased vision and it is difficult to finger stick test.The Plan denied your request. The Plan says the documentation shows you are not testing four or more times a day and thatthere is no evidence you are insulin treated.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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met.Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring (CGM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home blood glucose monitor and supplies.You asked the Plan to pre-approve a home blood glucose monitor and supplies. You say that this will help you avoid Type 2 diabetes.The Plan denied your request. The Plan says that home blood glucose monitors are only covered if you have diabetes.The Plan must follow Medicare rules. Medicare rules say that home blood glucose monitors are only covered if the beneficiary has diabetes. We looked at the file and Medicare rules. The file indicates you do not have diabetes. Based on this information, we decided that Medicare rules for coverage of a home blood glucose monitor and supplies have not been met.Therefore, we decided that the Plan does not have to pre-approve a home blood glucose monitor and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on November 21, 2019.
You asked the Plan to waive the copayment for an eye exam. You say that you were told that you would not owe a copayment. 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 $50 copayment for each exam to diagnose and treat diseases or conditions of the eye. The medical records show that you received an eye exam to diagnose or treat a condition on November 21, 2019. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for an eye exam. An eye exam falls 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 an eye exam provided on November 21, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services provided from October 8, 2017 to November 30, 2017.
You asked the Plan to pay for home health care services. You say that this should be covered. The Plan denied your request. The Plan says these services were provided by a provider who does not participate in Medicare.
The Plan must follow Medicare rules. Medicare rules say that home health services are covered only when the home health agency that is providing the services to the beneficiary has in effect a valid agreement to participate in the Medicare program We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care services have not been met. The provider you received these services from does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for home health care services provided from October 8, 2017 to November 30, 2017.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on December 13, 2019.You asked the Plan to waive the copayment forthe CT scan. You say that it is medically necessary to have the CT scan every 3 months to track your condition. You say you would like theinsurance to pay for the CT scan. 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 $150 copayment for in-network CT scans. You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within "Outpatient diagnostic tests and therapeutic services and supplies" 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 forthe CT scan provided on December 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 29, 2019 and January 7, 2020 by an OON provider.You asked the Plan to pay for the nursing home physician visits. You say that the authorizations were denied for these dates of service.The Plan denied your request. The Plan says the services were rendered by an OON provider. The Plan also says that prior 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 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 November 29, 2019 and January 7, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power mobility device (PMD) for the enrollee.You asked the Plan to pre-approvea PMD. The Plan denied your request. The Plan says that they have not received a prescription for this device from the enrollee's doctor.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a physician order. The record shows that the enrollee's physician did not submit a prescription for a PMD. The record does not contain a valid physician order for a PMD.Therefore, we decided that the Plan does not have to pre-approvea power mobility device (PMD) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bathtub lift (E0625).
You asked the Plan to pre-approve the bathtub lift. You say that the bathtub lift is medically necessary. The Plan denied your request. The Plan says bathtub lifts are not a covered item.
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 a bathtub lift (E0625).
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 November 8, 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; therefore the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the skilled nursing facility (SNF) services provided to the enrollee from September 11, 2019 to September 24, 2019.
You asked the Plan to waive the coinsurance for the SNF services. You say that since you were never told that the provider was out-of-network, this should be processed at the in-network rate. The Plan denied your request. The Plan says that the enrollee is responsible for the coinsurance.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% coinsurance for each SNF stay received out-of-network. You have been asked to pay a 40% coinsurance for the SNF services. The SNF services falls within the SNF stay received out-of-network 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 skilled nursing facility (SNF) services provided to the enrollee from September 11, 2019 to September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a preferred plan provider.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 office visits to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services provided on December 20, 2019.You asked the Plan to waive the copayment for urgent care services. You say that you disagree with the charges because you saw a primary care provider.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 $45 copayment for each visit to providers other than a primary care physician for urgently needed services.The record shows that you received urgent care services on December 20, 2019 from a provider other than your primary care physician. Therefore, you are responsible to pay the $45 copayment.  You have been asked to pay a $45 copayment for urgent care services. Urgent care services fall within the urgently needed 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 urgent care services provided on December 20, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for lumbar/sacral orthosis provided on January 24, 2018.
You asked the Plan to waive the coinsurance for lumbar/sacral orthosis. You say that you cannot afford 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment and related supplies. You received lumbar/sacral orthosis on January 24, 2018. The allowed amount is $979 and 20% of that is $195.80. You have been asked to pay the total coinsurance amount of $195.80 for lumbar/sacral orthosis. Lumbar/sacral orthosis falls within the durable medical equipment 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 lumbar/sacral orthosis provided on January 24, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sara Plus Sit to Stand Lift.
You asked the Plan to pre-approve these services. You say that your current seat lift does not provide the back support your require. The Plan denied your request. The Plan says that you have normal strength and gait.
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 these services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The documentation does not reveal a detailed objective neuromuscular or gait evaluation on a physical examination by your physician. There are no objective imaging studies included in the documentation revealing significant arthritis of your hip or knee or a diagnosis of a condition such as a progressive severe neuromuscular disease. There is no evidence that you are unable to stand up from a regular chair in your home. There is no evidence that the seat lift device will arrest or retard deterioration in your condition. There is no evidence that the seat lift mechanism will be safe and effective as you are noted to have unsteadiness on your feet and dementia. Our physician reviewer found that your condition does not meet criteria for coverage of this item. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Sara Plus Sit to Stand Lift.