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

We decided that the Plan does not have to pay for the drug testing rendered on December 10, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99213) provided on October 24, 2019.You asked the Plan to pay forthe office visit. You say that you would like reconsideration because it is imperative that this provider continues to work with you as he knows you best and understands your condition.The Plan denied your request. The Plan says these services were rendered by a Medicare opt-out physician; therefore, payment cannot be made.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a Medicare opt-out provider. This provider has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay foran office visit (99213) provided on October 24, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the diagnostic imaging you received on November 21, 2019.
You asked the Plan to waive the copay for the imaging services. You say that the doctor's office told you there was no copay. The Plan denied your request. The Plan says the copay was applied based on 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 a $200 copay for each type of Medicare-covered diagnostic radiology service including MRI, CT scans, nuclear scans, and PET scans. You have been asked to pay a $200 copay for the imaging services. The service 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 copay for the diagnostic imaging you received on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital hearing aids (V5261) rendered by the out of network (OON) provider on November 26, 2019.
You asked the Plan to pay for the hearing aids. You say that you are requesting a reconsideration of the Plan's denial for payment as you were not aware that this provider is out of network. The Plan denied your request. The Plan says that the hearing aids 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the digital hearing aids (V5261) rendered by the out of network (OON) provider on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood bank physician services rendered on October 24, 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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the blood bank physician services rendered on October 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a clinical trial/clinical research study.
You asked the Plan to pre-approve the services. You say that this is a Medicare-approved clinical trial. The Plan denied your request. The Plan says medically necessary services once an MA member is enrolled in a clinical trial are paid for by Original fee-for-service Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the services as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve a clinical trial/clinical research study.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lenses and frames purchased on May 14, 2019.
You asked the Plan to pay for the lenses and frames. You say that you were told you could get your prescription filled at this facility. The Plan denied your request. The Plan says that you were assessed correctly because you did not purchase your eyewear from a plan optical facility.
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 purchased from a plan optical facility. We looked at the file and the Plan's rules. The file indicates the lenses and frames were not purchased from a plan optical facility. Based on this information, we decided that the Plan's rules for coverage of the lenses and frames have not been met. Therefore, we decided that the Plan does not have to pay for the lenses and frames purchased on May 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a neck spine x-ray (72040-26) provided on December 19, 2019 by the appealing provider.
You asked the Plan to pay for the neck spine x-ray. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says the billed code is a duplicate claim line. Based on Medicare billing criteria, duplicate claims are not eligible for payment.
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 72040-26 is a neck spine x-ray. We find that CPT code 72040-26 is not supported in the medical record. Specifically, each claim was billed as 72040-26 which is duplicate billing. Code 72040-26 was already paid by the plan. Based on this information, we decided that Medicare rules for coverage of the neck spine x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a neck spine x-ray (72040-26) provided on December 19, 2019 by the appealing provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the stress test and the medical supply provided on December 16, 2019. You asked the Plan to waive the cost share for the stress test and the medical supply. You say that you were told your copayment for the test would be $200. You say you are questioning the two additional charges and that these charges should be a part of the test. 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 $75 copayment for Medicare-covered non-radiologic diagnostic procedures and tests and 20% of the cost for each Medicare-covered medical supply. You have been asked to pay a total of $118.34 for the stress test and the medical supply. The stress test and the medical supply 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 cost share for the stress test and the medical supply provided on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the services rendered to you on November 7, 2018 and November 16, 2018. You asked the Plan to waive the cost sharing for these services. You say that you were not aware you owed for these 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 $70 copayment for services obtained from a specialist in a specialist's office and a 40% coinsurance for an out-of-network Medicare-covered colorectal cancer screening exam. Review of the file shows that you received specialist services on November 7, 2018. You have been asked to pay a $70 copayment for these services. These services fall within the services obtained from a specialist in a specialist's office 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 colorectal cancer screening on November 16, 2018 from an out-of-network provider. You have been asked to pay a 40% coinsurance for these services. These services fall within the out-of-network Medicare-covered colorectal cancer screening exam 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 cost sharing for the services rendered to you on November 7, 2018 and November 16, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on November 19, 2019.
You asked the Plan to waive the copayment for an EGD. You say that you had the EGD done during a colonoscopy and feel that the $300 charge should be covered. The Plan denied your request. The Plan says the claims were processed 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 $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you received an EGD on November 19, 2019. An EGD is considered a diagnostic outpatient surgical procedure. Therefore, you are responsible to pay the $300 copayment. You have been asked to pay a $300 copayment for an EGD. An EGD 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 for an EGD provided on November 19, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton treatment therapy for the enrollee.You asked the Plan to pre-approve the therapy. You say that this is medically necessary.The Plan denied your request. The Plan says no definitive data exists to show that proton therapy is superior to IMRT for prostate cancer treatment.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 the therapy. Our reviewer says that the requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found any potential benefit or detriment of proton therapy over standard IMRT for routine cases is an investigational. While some may argue that it is standard practice to treat prostate cancer with proton therapy, both ASTRO and the NCCN guidelines recommend against routine use of proton therapy. Proton therapy would arguably exceed the enrollee's needs.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 therapy have not been met.Therefore, we decided that the Plan does not have to pre-approve proton treatment therapy for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient rehabilitation services provided from October 3, 2019 to October 22, 2019.You asked the Plan to pay for inpatient rehabilitation services. You say that you are Medicare certified.The Plan denied your request. The Plan says there is no Medicare ID on file.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We find that these services are not supported. Specifically, neither the NPI nor provider number were provided on the claim. The certification from CMS says that this should be reported on all correspondence. Based on this information, we decided that Medicare rules for coverage of inpatient rehabilitation services have not been met.Therefore, we decided that the Plan does not have to pay for inpatient rehabilitation services provided from October 3, 2019 to October 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the BRCA genetic testing rendered on April 17, 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 BRCA testing of an unaffected Medicare eligible individual or family member is not a covered Medicare benefit. We looked at the file and Medicare rules. The file shows that the enrollee did not have a personal history of cancer for which BRCA testing is covered. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the BRCA genetic testing rendered on April 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit, laser destruction, injections and ultrasounds provided from February 26, 2019 through May 14, 2019. You asked the Plan to waive the cost share for the office visit, laser destruction, injections and ultrasounds. You say that you were informed that you were fully covered. You say that the claim should not be denied. The Plan denied your request. The Plan says the cost share 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 out-of-network physician specialist services and 35% coinsurance for out-of-network diagnostic radiology. You have been asked to pay a total of $655.44 for the office visit, laser destruction, injections and ultrasounds. The office visit, laser destruction and injections fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The ultrasounds fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the services were covered at the out-of-network benefit rate. 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 cost share for the office visit, laser destruction, injections and ultrasounds provided from February 26, 2019 through May 14, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve34 additional outpatient physical therapy visits.You asked the Plan to pre-approve the additional visits. You say that this is medically necessary.The Plan denied your request. The Plan says only two of the original 36 requested visits can be approved.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the documentation does not reveal evidence of any significant objective functional deficits that require ongoing skilled therapy beyond what was approved by the plan. You do not require an additional 34 additional sessions of therapy to transition to a home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.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 additional visits have not been met.Therefore, we decided that the Plan does not have to pre-approve34 additional outpatient physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services you provided on November 18, 2019. You asked the Plan to pay for the physician's 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 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 you provided on November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 26, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were 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 drug testing services provided to the enrollee on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for spinal surgery services (2260, 63045, 22842 and 22614) provided on October 9, 2019.You asked the Plan to pay for the surgery services. You say that you would like reconsideration because this procedure allows for assistant at surgery services.The Plan denied your request. The Plan says procedures billed with the assistant-at-surgery physician modifiers may only be applied for physician assistants, nurse practitioners and clinical nurse specialists.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician,PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay for spinal surgery services (2260, 63045, 22842 and 22614) provided on October 9, 2019.
Appeal type: Inpatient Hospital
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 November 17, 2019, and November 18, 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 November 17, 2019, and November 18, 2019.