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

We decided that the Plan has to pay for Tempus XT gene panel testing.

You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician regarded this testing as a medically necessary and valuable tool when determining treatment. The Plan denied your request. The Plan says that the denial of payment for this test is correct, because the Tempus XT panel is not an approved test with the Medicare contract and this lab is not listed as a Clinical Laboratory Improvement Amendments (CLIA)-approved lab.

The Plan follows Medicare rules. Medicare rules state that next generation sequencing testing is nationally covered under certain conditions.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for genetic testing. Our reviewer says that this testing meets the Medicare criteria for coverage. Our physician reviewer found next generation sequencing (NGS) is considered a standard of care in determining treatment for esophageal cancer. Per the National Comprehensive Cancer Network (NCCN) guidelines for esophageal cancer: Next-generation sequencing (NGS) offers the opportunity to assess numerous mutations simultaneously, along with other molecular events such as amplification, deletions, tumor mutation burden, and microsatellite instability status. NGS can be considered instead of sequential testing for single biomarkers when limited diagnostic tissue is available or when the patient is unable to undergo a traditional biopsy. It should be noted that NGS has several inherent limitations and thus whenever possible, the use of gold-standard assays (IHC/ISH) should be performed first and if sufficient tissue is available, additional NGS testing may be considered. The service was reasonable and 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 genetic testing have been met. Therefore, we decided that the Plan has to pay for Tempus XT gene panel testing.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for photocromic tint (V2744), anti-reflective coating (V2750),
and polycarbonate lenses (V2784) provided on November 21, 2020.
You asked the Plan to pay for the lens upgrades. You say that you did not have the option to not get these
upgrades, and they should be covered by the Plan. The Plan denied your request. The Plan says additional
options for routine eyewear including, but not limited to, tinting, polycarbonate and anti-reflective coating are
not covered.
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's contract clearly states that tinting, polycarbonate and anti-reflective coating are not
covered.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan does not have to
pay for photocromic tint (V2744), anti-reflective coating (V2750), and polycarbonate lenses (V2784) provided
on November 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit.

You asked the Plan to waive the copayment for the telehealth visit. You say that it is state law that a telehealth copayment is $0. 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 $25 for each covered visit or consultation in an outpatient location with a specialist.

You have been asked to pay a $25 copayment for the telehealth visit. The telehealth visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan says that non COVID related telehealth services will have the same copayment as an in-person visit. 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 telehealth visit.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ground mileage charges applied by the provider for ambulance transport.

You asked the Plan to pay for the charges for ground mileage. You say that the treatment you needed could not be provided in the originating hospital and you were transferred for treatment. You state the Plan should pay this mileage. The Plan states the transport itself was paid (minus your $250 copayment) because it was agreed the originating hospital could not provide treatment. However, it was noted that this treatment could have been provided to the nearest hospital and therefore you were not transported to the closest destination that could provide treatment. Therefore, the residual charges, such as mileage, are not covered by the Plan.

Medicare only fully pays for transfer from one hospital to another when an enrollee is transported to the nearest hospital that is capable to provide the required treatment. The Plan paid for the actual transport and not the mileage because you could have gone to one hospital to another hospital. This would correct in accordance with the Medicare guidelines. Therefore, we decided that the Plan does not have to pay for ground mileage charges applied by the provider for ambulance transport.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 16, 2020.
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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on September 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397)
provided September 28, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were
medically necessary. The Plan denied your request. The Plan says there was no history between the ordering
physician and the enrollee prior to the items being ordered.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve
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 knee orthosis and suspension sleeve. Our
reviewer says that the items provided were not medically reasonable and necessary. Our physician reviewer
found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient
credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately
payable when the base item is not covered.
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 knee orthosis and suspension sleeve have not been met. Therefore, we
decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397)
provided September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the $15 copayment charged for diagnostic vision services provided on August 19, 2020.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says he claim was submitted to their vision plan for review and they have issued a reimbursement to you for $40 for procedure code 92015 (determination of refractive state) on February 08, 2021. The Plan states procedure code 92014 (ophthalmological services: medical examination and evaluation) was processed correctly. The Plan states according to page 96 of your 2020 Evidence of Coverage (EOC), you are responsible for a $0 copayment or $15 copayment for Medicare covered Vision Services depending on your level of Medicaid eligibility. The Plan states that based on your personal Medicaid eligibility your copayment would be $15. The Plan states billed diagnosis and procedure codes indicate the services provided were medical in nature; therefore, no changes can be made to your 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 $15 copayment for vision services depending on your Medicaid eligibility. 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 $15 copayment charged for diagnostic vision services provided on August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure and additional intraoral periapical x-ray.

You asked the Plan to pay for the preventive procedure and additional intraoral periapical x-ray. You say that you would like these services to be covered. The Plan denied your request. The Plan says the preventive procedure is not covered. The Plan also says that your benefits for the additional intraoral periapical x-ray have been satisfied and the frequency limitation has been exceeded.

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, unspecified preventive procedure is not among those covered under this benefit. The contract also states that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray and your intraoral x-rays benefit has been exhausted. The record also shows that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility. Therefore, we decided that the Plan does not have to pay for the preventive procedure and additional intraoral periapical x-ray.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided from October 30, 2020, to November 1, 2020.
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that this bill should be covered by the Plan. The Plan denied your request. The Plan says payment for self-administered drugs is submitted as a claim to your Medicare Part D carrier.
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 pay for self-administered drugs provided from October 30, 2020, to November 1, 2020.
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 pay for chiropractic services other than manual manipulation.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says only those services directly related to manual manipulation of the
spine are covered.

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 service at issue is not
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic
services other than manual manipulation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies for a ramp purchased October 17, 2020.
You asked the Plan to pay for supplies for a ramp. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this service is not covered.
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 pay for the supplies for a ramp purchased October 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services.

You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the surgical pathology 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 surgical pathology services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $50 copayment charged for ambulance transport provided on October 2, 2020.
You asked the Plan to waive this copayment. You say that you do not believe this bill is correct. The Plan denied your request. The Plan says this copayment was applied based on the services provided and the Plan contract agreement.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each one-way ambulance transport. You have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the $50 copayment charged for ambulance transport provided on October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99213) change of cystostomy tube (51705) provided on July 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that this appointment happened during the time where the office started seeing patients back in the office after all of the doctors had not been able to have in office appointments. So was not able to get authorization for date of service. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99213) change of cystostomy tube (51705) provided on July 7, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on October 28, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you were told this service was 100% covered and a $0 copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $225 copayment for Medicare-covered diagnostic radiology in an outpatient hospital setting. You have been asked to pay a $225 copayment for the CT scan. The CT scan 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 CT scan provided on October 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular junction testing (code 95937) provided on November 6, 2020.
You asked the Plan to pay for neuromuscular junction testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this testing is not covered for the diagnosis codes billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that neuromuscular junction testing code 95937 is only covered when performed for certain, specific diagnoses. We looked at the file and Medicare rules. This service was not billed with a covered diagnosis code. Based on this information, we decided that Medicare rules for coverage of neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular junction testing (code 95937) provided on November 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that you need the requested item because you have been sleeping on a broken mattress. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a powered pressure reducing mattress overlay (E0181). A powered pressure reducing mattress overlay (E0181) serves the same purpose as a powered pressure-reducing air mattress. Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).
Your complaint about being poorly treated by representatives of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SPECT test provided on September 3, 2020.
You asked the Plan to waive the copayment for the SPECT test. You say that you had the same insurance and received the same service from the same provider in 2019 and was not charged a copayment. The Plan denied your request. The Plan says the claim was reprocessed, and you have been asked to pay 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 $50 copayment for in-network diagnostic procedures and tests. You have been asked to pay a $50 copayment for the SPECT test. The SPECT test 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 SPECT test provided on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the resin-based composite.

You asked the Plan to pay more for the resin-based composite. You say that you would like this service to be covered. The Plan denied your request. The Plan says the coinsurance amount you are being charged for this service is correct.

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, you are responsible for a 20% coinsurance for Class 2 Basic Services, which includes white fillings on front teeth. Therefore, we decided that the Plan does not have to pay more for the resin-based composite.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient services.

You asked the Plan to pay for the hospital outpatient services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the hospital outpatient 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 hospital outpatient services.