Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a PCD (E0676) provided to the enrollee on December 20, 2019.You asked the Plan to pay for the PCD. You say that the claim should be paid.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the PCD is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting. As a non-covered service it is not a benefit when ordered by either a contracted or a non-contracted provider. Additionally, Medicare rules say that CMS does not pay for non-professional services to any provider or supplier other than the facility or hospital for services furnished to the beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made between the facility and hospital and outside providers. The enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included in the facility DRG or PPS payment. Payment for this service is the responsibility of the facility or hospital that provided the surgery.Therefore, we decided that the Plan does not have to pay for a PCD (E0676) provided to the enrollee on December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor provided on December 3, 2019.You asked the Plan to pay for the supply allowance. You say that the Plan should pay this claim.The Plan denied your request. The Plan says there is no itemized shipping/billing invoice to indicate the specific supplies, or Proof of Delivery indicating the billed items were delivered.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. There is no invoice or proof of delivery.Therefore, we decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor provided on December 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for eye surgery provided on April 3, 2019.You asked the Plan to waive the copayment for eye surgery. You say that your eye was injured during surgery. You say that you should be refunded.The Plan denied your request. The Plan says the copayment 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). Your contract with the Plan clearly says that you must pay a $275 copayment for in-network ambulatory surgical center services.You have been asked to pay a $275 copayment for eye surgery. Eye surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the surgery was performed. 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 eye surgery provided on April 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the abdomen and pelvis (74177) provided February 3, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 $205 copayment for Outpatient Diagnostic Radiology. You have been asked to pay a $205 copayment for the CT scan. The CT scan falls within the Outpatient Diagnostic Radiology 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 Computed Tomography (CT) of the abdomen ad pelvis (74177) provided February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 4, 2019.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.

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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visual field exam provided on December 23, 2019.
You asked the Plan to waive the copayment for the visual field exam. You say that you've been having the same eye exam for years. You say that you've never had to pay extra. The Plan denied your request. The Plan says the copayment 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). Your contract with the Plan clearly says that you must pay $20 per day for Medicare-covered tests. You have been asked to pay a $20 copayment for the visual field exam. The visual field exam 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 visual field exam provided on December 23, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Planhasto pay fordrug testing services provided to the enrollee on May 23, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says that the denied codes remain not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of the denied codes is:HCPCS G0483:Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed CPT 80307:Drug tests(s), presumptive, any number of drug classes, qualitative, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service. 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 the services. Our reviewer says that the services at issue in this case are supported by the medical records. Our physician reviewer found it is not clear how a test to see if someone is getting medications from an outside source can be specific. The purpose of the test is to screen for scheduled drugs that many doctors demand patients disclose as part of a contract that will allow them to continue to prescribe the medications. Therefore, they have no way of knowing what drugs would be being abused.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 services have been met.Therefore, we decided that the Plan has to pay for drug testing services provided to the enrollee on May 23, 2019. If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a Rituxan 500mg/50ml vial for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says that the reference books and coverage determinations do not support using this drug to treat stage III chronic renal disease with acute renal injury.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 the drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found coverage of Rituxan 500 mg/50 ml vial is requested treatment of bullous pemphigoid in this 84 year old woman with type II diabetes mellitus, and chronic kidney disease with superimposed acute kidney injury requiring hospitalization on May 2, 2020. The diagnosis requiring Rituxan is well documented in the medical record in a note by the Dermatology resident dated May 3, 2020. The biopsy report including positive direct immunofluorescence are included in the medical record. The use of Rituxan for the noted indication is supported in UpToDate, and sufficient documentation has been provided as to why Rituxan is the best treatment option for this enrollee. The documentation provided supports that Rituxan is safe and effective for treatment of the enrollee's condition, and is medically reasonable and necessary.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 drug have been met.Therefore, we decided that the Plan has to pre-approve a Rituxan 500mg/50ml vial for the enrollee.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for melanoma testing provided to the enrollee on August 7, 2019.
You asked the Plan to pay for this testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 this testing. Our reviewer says that medical necessity for this testing was not established. Our physician reviewer found the enrollee had a pT1A malignant melanoma of the right upper extremity. Depth was 0.5 mm with no identified mitotic count, no ulceration and no perineural or angiolymphatic invasion. There is no documentation that results of this test will be clinically relevant in determining need for adjuvant immunotherapy. The requested melanoma testing is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for melanoma testing provided to the enrollee on August 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDaliresp.You asked the Plan to pre-approveDaliresp. You say that the enrollee has done remarkably well on this medication.The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 pre-approveDaliresp.Benefits for Dalirespmay be available under Medicare Part D.Contactthe 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 deductible for the office visit, arthrocentesis, ankle x-ray and triamcinolone acetonide injection provided on September 17, 2019.You asked the Plan to waive the deductible for the office visit, arthrocentesis, ankle x-ray and triamcinolone acetonide injection. You say that the doctor is certified to perform the service. You say that the claim was processed incorrectly.The Plan denied your request. The Plan says the deductible applied correctly.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 your deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services.The office visit and arthrocentesis fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The ankle x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The triamcinolone acetonide injection falls within the "Medicare Part B Prescription Drugs"benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the office visit, arthrocentesis, ankle x-ray and triamcinolone acetonide injection were received on September 17, 2019.Therefore, we decided that the Plan does not have to waive the deductible for the office visit, arthrocentesis, ankle x-ray and triamcinolone acetonide injection provided on September 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exam (D0150) provided January 6, 2020.You asked the Plan to pay for the dental services. You say that this evaluation was necessary because it was your first appointment with your new provider. You have many dental issues relating to diagnosis of cancer, kidney disease and behavioral health issues.The Plan denied your request. The Plan says this request exceeds the benefit frequency limitation.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. This service is covered once every 3 years. Records show that this service was provided July 18, 2018.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 comprehensiveoral exam (D0150) provided January 6, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV solution and infusion, laboratory services, radiologic examination, CT, and ED visit provided.
You asked the Plan to pay for the IV solution and infusion, laboratory services, radiologic examination, CT, and ED visit. You say that the claim has not been paid in full or under the terms o 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 IV solution and infusion, laboratory services, radiologic examination, CT, and ED visit provided.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of inpatient skilled nursing facility care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee does not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have complex wounds, new enteral feedings, IV antibiotics or other skilled nursing level of care need. The enrollee's functional level does not require skilled therapy services on a daily basis with the specialized skill, knowledge and judgement of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a skilled nursing facility. As a practical matter the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 inpatient skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by an out-of-network provider 
You asked the Plan to waive the copayment for physical therapy. You say that you would like these services processed as in-network. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $65 copayment for outpatient rehabilitation services/out-of-network/physical therapy. You have been asked to pay a $65 copayment for physical therapy. The total amount you are being asked to pay is $1,209.83 ($65 x 16 visits = $1,040 + $58.91 + $52.01 + $58.91 = $1,209.83). The correct copayment has been applied to the services that were provided. Physical therapy falls within the outpatient rehabilitation services/out-of-network/physical therapy 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 physical therapy provided by an out-of-network provider