Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polycarbonate lenses (V2784) anti-reflective coating, per lens (V2750) for eyeglasses purchased January 15, 2020.
You asked the Plan to pay for the vision services. You say that the plan should charge an additional fee for office visit to see specialists so that those items can be added to the routine vision benefit. The Plan denied your request. The Plan says these services are not covered under the plan benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when enhancements (upgrades) are not covered through the eyewear allowance and may be purchased by the member at an additional cost. The eyewear allowance covers standard contact lenses or eyeglasses, single vision or lined multi-focal lens and frames (lined bifocal and lined trifocal lenses). We looked at the file and the Plan's rules. Enhancements and upgrades are not covered by the plan. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for polycarbonate lenses (V2784) anti-reflective coating, per lens (V2750) for eyeglasses purchased January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient diagnostic services rendered on September 23, 2019 and October 28, 2019.
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were 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 $70 copayment for laboratory services in an outpatient hospital and a $95 copayment for basic radiological services at an outpatient hospital.
The file shows that you received laboratory services at an outpatient hospital on September 23, 2019. You have been asked to pay a $70 copayment for these services. These services fall within the laboratory services in an outpatient hospital 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.
The file shows that you received a hip x-ray at an outpatient hospital on October 28, 2019. Per your contract with the Plan, there is a $95 copayment for basic radiological services at an outpatient hospital. However, the Medicare allowed amount for these services was $57.83. Given that the allowed amount was less than the $95 copayment, you have been asked to pay $57.83 for these services.
Therefore, we decided that the Plan does not have to waive the copayments for the outpatient diagnostic services rendered on September 23, 2019 and October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 25, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pin retention (D2951) provided on February 3, 2020.
You asked the Plan to pay for the pin retention (D2951). You say that the pin retention should be covered because it was used to make the tooth stronger to hold the filing. The Plan denied your request. The Plan says the service is not covered benefits.
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 pin retention (D2951) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pin retention (D2951) provided on 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 22, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is not a valid referral for this service.
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 physician's services. 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 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport services provided on June 15, 2019.
You asked the Plan to pay for the ambulance transport services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes A0429 and A0425 for the ambulance transport and the mileage were billed incorrectly. Specifically, these codes were billed with modifier GM which is for multiple patient transports. The correct modifiers identifying the place of origin and destination must be submitted on these claims. Based on this information, we decided that Medicare rules for coverage of the ambulance transport services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transport services provided on June 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a valid order identifying what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on September 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 19, 2019.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that 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 $295 copayment for each covered, one-way ambulance trip by ground or water. You have been asked to pay a $265.06 copayment for the ambulance transport. The ambulance transport falls within the covered, one-way ambulance trip by ground or water benefit category. This means that you have been asked to pay less than the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray rendered on December 21, 2019.
You asked the Plan to waive the copayment for these services. You say that you did not have the services. The Plan denied your request. The Plan says the copayment was 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 $40 copayment for each Medicare-covered therapy visit.
Review of the file shows that you received a contrast x-ray on December 21, 2019. You have been asked to pay a $45 copayment for these services. These services fall within the Medicare-covered standard x-ray 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 x-ray rendered on December 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and cancer screening provided by an out of network provider on October 24, 2019.
You asked the Plan to pay for the office visit and cancer screening. You say that you disagree with the amount reimbursed. The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay for out of network.
Review of the file shows that the amount allowed for the office visit was $65. You were charged a coinsurance amount of 20%, which is $13. There is also a 2% sequestration applied when you receive services from an out of network provider, which equals $1.04. Therefore, you were reimbursed the difference of $50.96 for the office visit.
The allowed amount for the cancer screening is $37.79. You were charged a 2% sequestration since you received these services from an out of network provider, which equals $.76. Therefore, the amount reimbursed for the cancer screening was $37.03. You have been asked to pay the difference for the office visit and cancer screening. Since you received these services from an out of network provider, the office visit and cancer screening falls within the 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 pay for the office visit and cancer screening provided by an out of network provider on October 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ExoDx Prostate IntelliScore testing rendered on October 8, 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 the testing is not covered.
The Plan must follow Medicare rules. The rules say that biomarkers (specifically, EPI, MiPS, and SelectMDx) are deemed investigational. The testing at issue is the ExoDx Prostate Intelliscore (EPI) test. This test is considered investigational by Medicare and is therefore not covered. Therefore, we decided that the Plan does not have to pay for the ExoDx Prostate IntelliScore testing rendered on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 12, 2019 by a non-network provider.
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 were rendered by a non-network provider without prior authorization.
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 December 12, 2019 by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 2, 2019 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 approved for payment. The Plan denied your request. The Plan says no prior authorization was 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 lab work provided on December 2, 2019 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 the outpatient hospital services rendered on October 25, 2019.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was 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 $200 copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, observation room, or outpatient surgery services.
Review of the file shows that you received outpatient hospital services on October 25, 2019. You have been asked to pay a $200 copayment for these services. These services fall within the Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, observation room, or outpatient surgery 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 outpatient hospital services rendered on October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intermittent limb compression device.
You asked the Plan to pre-approve intermittent limb compression device. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the records indicate that the enrollee only has swelling in the legs.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 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 intermittent limb compression device. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested pneumatic compression device. Our physician reviewer found based on the medical records provided there is no evidence that the enrollee's lymphedema extends onto the chest, trunk, and/or abdomen. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve intermittent limb compression device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically necessary based on your medical stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0480 provided on December 10, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 code G0480 is 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; 1-7 drug class(es), including metabolite(s) if performed. We find that CPT code G0480 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of interpretation results of confirmatory drug testing. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0480 provided on December 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital, having been admitted with respiratory failure. The enrollee was subsequently treated for pneumonia, intermittent rapid rate atrial fibrillation and a rectus sheath hematoma. The enrollee was intubated/ventilated and, after several failed attempts at extubation, received a tracheotomy. The enrollee remains on a ventilator, though shows some evidence of recent weaning success. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such time no acute services are required. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.