Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 25, 2019 to November 26, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that you went to the emergency room for your blood pressure problem.The Plan denied your request. The Plan says you have no out of network benefits.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The file shows that you received office visits from a provider that is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay forthe medical services provided on November 25, 2019 to November 26, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80156, 80157, 80177, 80201, 80159, and 80173 provided on August 1, 2019.
You asked the Plan to pay for the laboratory services. 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. We find that CPT codes 80156, 80157, 80177, 80201, 80159, and 80173 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records for the laboratory services provided. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80156, 80157, 80177, 80201, 80159, and 80173 provided on August 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October 26, 2019.You asked the Plan to waive the copayment for laboratory services. You say that you are being charged twice for laboratory services and disagree with 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 a $20 copayment per visit for laboratory tests. You have been asked to pay a $20 copayment for laboratory services. Laboratory services fall 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 laboratory services provided on October 26, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray consultation (76140) provided on August 14, 2019.
You asked the Plan to pay for the x-ray consultation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 76140 has a status code of I which is not valid for Medicare purposes. 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 code 76140 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 76140 has a status code of I. This means that CPT code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the x-ray consultation have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray consultation (76140) provided on August 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental exam you received on November 20, 2019.
You asked the Plan to pay for the dental service. You say that limited exams other than cleanings should be covered as part of the plans benefits. The Plan denied your request. The Plan says the service is limited to twice per calendar year.
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.
We looked at the file, and Medicare rules. The file shows that you received 2 oral exams prior to the date of service at issue. Your plan only covers 2 exams per calendar year. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does not have to pay for the dental exam you received on November 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 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 step therapy guidelines were not followed.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 not medically reasonable or necessary. Our physician reviewer found the enrollee has not tried and failed Zoledronic acid. The documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on December 1,
2019 through December 8, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because
per Medicare, CPT code S9328 is valid. The Plan denied your request. The Plan says CPT code S9328 has a
status code of I which is not valid for Medicare purposes.
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 code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code S9328 has a status code of I. This means the CPT code S9328 is not valid for Medicare purposes. Based
on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been
met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on
December 1, 2019 through December 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the endoscopy provided on August 5, 2019.
You asked the Plan to reduce the copayment for the endoscopy. You say that you should have had the procedure done at a hospital you would have only had a $30 copayment. 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 35% coinsurance. for Medicare-covered surgery at an out-of-network ambulatory surgical center. You have been asked to pay $140.81 which is 35% of the allowed amount for the endoscopy. The allowed amount is $402.32. ($402.32 x 35% = $140.81). The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the endoscopy was performed at an out-of-network ambulatory surgical center.
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 reduce the copayment for the endoscopy provided on August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on September 9, 2019.
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says rules for telehealth services have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acupuncture services you received on September 19, 2019.You asked the Plan to pay forthe acupuncture services. You say that you were paid incorrectly for the services.The Plan denied your request. The Plan says the acupuncture services must be performed by a licensed physician.The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. The records do not show that the provider at issue is a legally qualified physician. Based on this information, we decided that Medicare rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pay for the acupuncture services you received on September 19, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 25, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 laboratory services provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says authorization is required before out-of-network care is rendered unless the care is urgent or emergent.
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 3, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea high strength, lightweight wheelchair (K0004).You asked the Plan to pre-approvea high strength, lightweight wheelchair. You say that you have problems with your knees and heart and it is hard for you to walk because you cannot breathe. You have waited too long for the right wheelchair to be approved.The Plan denied your request. The Plan says the requested item is not reasonable and necessary.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 a high strength, lightweight wheelchair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee cannot use a standard or light weight wheelchair to self-propel while engaging in frequent activities in the home. The documentation does not reveal that the enrollee requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a high strength, lightweight wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea high strength, lightweight wheelchair (K0004)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pre-employment exam you had on January 3, 2020.
You asked the Plan to pay for the exam. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that he routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury; and (b) examinations required by third parties such as insurance companies, business establishments, or Government agencies. We looked at the file and Medicare rules. The requested exam was performed for pre-employment purposes. This type of exam is not covered by Medicare or your plan. Based on this information, we decided that Medicare rules for coverage of the exam have not been met. Therefore, we decided that the Plan does not have to pay for the pre-employment exam you had on January 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 10, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on October 10, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance transport and mileage provided on May 14, 2019.
You asked the Plan to pay for the ambulance transport and mileage. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the mileage code is only allowable if A0426 or A0428 is allowed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that this claim was denied due to a modifier issue. The modifier billed with the claim was modifier SH. The modifiers billed with these codes appear to be correct and there is nothing that claims that these modifiers are invalid. The plan did not provide documentation to support their denial. Therefore, we decided that the Plan has to pay for the ambulance transport and mileage provided on May 14, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the EKG provided on October 28, 2019.
You asked the Plan to waive the coinsurance for the EKG. You say that you do not pay an additional cost for pre-operative testing. You say that this should be covered by insurance. The Plan denied your request. The Plan says the coinsurance 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% coinsurance for Medicare-covered non-radiological diagnostic services. You have been asked to pay $13.45, which is 20% of the allowed amount for the EKG. The allowed amount is $67.25 (20% x $67.25 = $13.45). The EKG falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 EKG provided on October 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forcataract removal provided on September 4, 2019.You asked the Plan to waive the copayment forcataractremoval. 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 a $200 copayment for outpatient surgery and other procedures. You have been asked to pay a $200 copayment for cataract removal. Cataract removal falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 forcataract removal provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 20, 2019 by an out of network (OON) 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 an out-of-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 November 20, 2019 by an out of network (OON) provider.