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

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules state that limited coverage is provided for the Decipher Biopsy Prostate Cancer Classifier Assay (Decipher Biosciences) for men with NCCN low risk and very low risk prostate cancer only when the following clinical conditions are met: -Needle biopsy with localized adenocarcinoma of prostate (no clinical evidence of metastasis or lymph node involvement), and -FFPE prostate biopsy specimen with at least 0.5 mm of cancer length, and -Patients with low risk or very low risk as defined by the NCCN as follows: -Low Risk: -Stage T1 or T2a -PSA less than 10 ng/mL -Gleason score 6 or less (Grade Group 1) OR -Very Low Risk: Stage T1c -PSA less than 10 ng/mL -Gleason score 6 or less (grade group 1) -Not more than two cores with cancer -Less than or equal to 50 percent of core involved with cancer -PSA density less than 0.15 -Patient has an estimated life expectancy of greater than or equal to 10 years, and -Patient is a candidate for and is considering conservative therapy and yet would be eligible for definitive therapy (radical prostatectomy, radiation therapy or brachytherapy), and -Result will be used to determine treatment between definitive therapy and conservative management by active surveillance (AS) and -Patient has not received pelvic radiation or androgen deprivation therapy prior to the biopsy, and -Patient is monitored for disease progression based on the established standard of care, including at least a repeat biopsy at 1 year. You can find the full rule in the Local Coverage Determination (LCD): MolDX: Decipher Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease (L37820).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Decipher Biopsy Prostate Cancer Classifier Assay provided to the enrollee.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this was not medically necessary.
The Plan follows Medicare rules. Medicare rules say that the Decipher Biopsy Prostate Cancer Classifier Assay (Decipher Biosciences) is covered for men with NCCN low risk and very low risk prostate cancer only when certain clinical conditions are met. 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 testing. Our reviewer says that the requested testing was not medically reasonable and necessary. Our physician reviewer found that the enrollee does not have very low risk or low risk prostate cancer, as required for coverage by LCD L37818. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for Decipher Biopsy Prostate Cancer Classifier Assay provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on August 21, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that the enrollee fractured her tooth while eating and was in pain and had sensitivity due to the fracture. You also say that the enrollee's visit was emergent in nature. The Plan denied your request. The Plan says the enrollee did not elect to purchase the Optional Supplemental Benefit plan. The Plan also says these services are 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on August 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forRadiation Oncology services (G6015, G6002) provided on August 12, 2019 by an out of network provider.You asked the Plan to pay forthe radiation oncology services. You say that the services were medically necessary.The Plan denied your request. The Plan says there were in-network providers available that could provide the same services.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 forRadiation Oncology services (G6015, G6002) provided on August 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Diagnostic Mammogram and Ultrasound (77065, 76641) provided May 26, 2019.You asked the Plan to waive the copayment for the Diagnostic Mammogram with Ultrasound. You say that the copayment for the mammogram should be waived.The Plan denied your request. The Plan says the services rendered were diagnostic in nature and not an annual screening mammogram, therefore the correct copayment 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 $100 copayment for Diagnostic Imaging. You have been asked to pay a $100 copayment for the Diagnostic Mammogram with Ultrasound. The Diagnostic Mammogram with Ultrasound falls within the Diagnostic Imaging 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 fora Diagnostic Mammogram and Ultrasound (77065, 76641) provided May 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe continuous glucose monitor (CGM) and supplies provided from April 17, 2019 to August 27, 2019 by an out of network provider.You asked the Plan to pay forthese services. You say that you did not request these items.The Plan denied your request. The Plan says that there was no authorization for these items.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 forthe continuous glucose monitor (CGM) and supplies provided from April 17, 2019 to August 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Albuterol inhaler provided on April 15, 2019.
You asked the Plan to pay for this drug. The Plan denied your request. The Plan says that this is not covered under Part B.
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 the Albuterol inhaler provided on April 15, 2019.
Benefits for this drug 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided at the Provider Medical Center on August 26, 2019.
You asked the Plan to waive the copayment for an ultrasound. You say that you 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 $0 copayment for diagnostic procedures and tests provided in a physician's office and a $99 copay when procedures are provided at any other location. You received an ultrasound at an outpatient hospital facility on August 26, 2019. Therefore, you are responsible to pay the allowed amount of $90.18, which is less than the $99 copayment. You have been asked to pay $90.18 for an ultrasound. An ultrasound 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 an ultrasound provided at at the Provider Medical Center on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography you received on July 12, 2019.You asked the Plan to waive the copayment. You say that the provider told you there would be no charge.The Plan denied your request. The Plan says you are responsible for the cost share.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 $100 copayment for each Medicare-covered radiological diagnostic service. Review of the file shows that you had an echocardiography on July 12, 2019. You have been asked to pay a $100 copayment for the echocardiography. The echocardiography falls within the outpatient diagnostic tests 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 echocardiography you received on July 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, panoramic x-ray, and prophylaxis provided on July 22, 2019.You asked the Plan to pay more for the periodic oral evaluation, panoramic x-ray, and prophylaxis. You say that at your visit the hygienist told you that your insurance would pay for the x-rays. You also say that this payment will be a financial burden to you.The Plan denied your request. The Plan says the services were performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the contract clearly states that there is a 50% coinsurance for periodic oral evaluations, panoramic x-rays, and prophylaxis when the services are received out-of-network. The record shows that you saw an out-of-network provider and the Plan does not have to pay the in-network benefit rates for these services.Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, panoramic x-ray, and prophylaxis provided on July 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided to the enrollee from August 19, 2019 to August 26, 2019.You asked the Plan to pay forthese services. You say that this should be covered as it is a valid procedure code according to Medicare.The Plan denied your request. The Plan says that this is not covered by Medicare.The Plan must follow Medicare rules. The rules say that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. You are billing for home infusion services S9328. This is not a valid code for Medicare purposes and the plan does not offer an additional benefit for this service.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided to the enrollee from August 19, 2019 to August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 16, 2019 to October 4, 2019.You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.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. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 16, 2019 to October 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on May 7, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly 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 drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided on May 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. 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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on August 8, 2019.You asked the Plan to waive the copayment for the upper GI endoscopy. You say that you have had this procedure previously and did not owe a 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 a $200 copayment for each Medicare-covered in-network outpatient hospital facility visit. You have been asked to pay a $200 copayment for the upper GI endoscopy. The upper GI 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 because of a dysphasia diagnosis. Therefore, the endoscopy is diagnostic in nature.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 upper GI endoscopy provided on August 8, 2019.Our decision is only about the August 8, 2019service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on February 25, 2019. You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee was under hospice election at the time of service.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 ambulance transport provided to the enrollee on February 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing for 22 or more drug classes provided on July 3, 2019.
You asked the Plan to pay for the definitive drug testing. You say that the order and progress note support intent and medical necessity. The Plan denied your request. The Plan says the order form provided is not valid as it is not signed and does not have sufficient detail.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the treating provider. In this case, the file shows that the practitioner protocol was ordered. However, the form which defines this protocol does not appear to indicate more than 22 drug classes. Without evidence of the intent to test for 22 or more drug classes, we find that this testing is not supported. Therefore, we decided that the Plan does not have to pay for the definitive drug testing for 22 or more drug classes provided on July 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan services provided on August 29, 2019 by out of network provider.
You asked the Plan to pay for the duplex scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 duplex scan services provided on August 29, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on February 7, 2019 by out of network provide.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 to the enrollee on February 7, 2019 by out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from May 4, 2019 to May 16, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the claims were not submitted on the appropriate Medicare required forms.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code and must be submitted on the appropriate Medicare Provider billing claim forms. In this case, the claim was inappropriately submitted. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from May 4, 2019 to May 16, 2019.