Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the One G5 System purchased on October 3, 2019.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that the provided canisters are of no use when you are out for more than an hour and a half. The Plan denied your request. The Plan says only rented oxygen equipment is eligible for coverage.
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. Medicare rules say that only rented oxygen equipment is eligible for coverage. The record shows that you have a stationary oxygen system with refillable portable tanks. This stationary oxygen system with refillable portable tanks meets your in-home needs and serves the same purpose as a portable oxygen concentrator. Purchased oxygen equipment is statutorily non-covered by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the One G5 System  on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy services provided to the enrollee on November 6, 2019.
You asked the Plan to pay for medical nutrition therapy services. You say that the services were medically necessary and appropriate. The Plan denied your request. The Plan says medical nutrition therapy is covered by Medicare only for diabetes and renal disease.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for the medical nutrition therapy services provided to the enrollee on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on November 4, 2019.
You asked the Plan to pay for the assembly and operation of a pump with oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) provided by the provider from April 15, 2019 to October 21, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit by Medicare or the health plan.
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 services provided do not meet Medicare criteria for coverage of chiropractic services and are not covered under the Plan contract. Therefore, we decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) provided April 15, 2019 to October 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic Resonance Imaging (MRI) of the Lumbar
Spine (72158) provided on November 8, 2019
You asked the Plan to pay for the MRI. You say that the services were medically necessary. The Plan denied
your request. The Plan says these services were not emergent or pre-authorized. There were network providers
available.
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 Magnetic Resonance Imaging (MRI) of the
Lumbar Spine (72158) provided on November 8, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the astigmatism-correcting intraocular lenses (A-C IOLs) rendered to you on July 10, 2019 and July 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 services are not covered.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the astigmatism-correcting intraocular lenses (A-C IOLs) rendered to you on July 10, 2019 and July 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Febuxostat, 40 mg tablet.
You asked the Plan to pre-approve Febuxostat. You say that the enrollee has tried other medications. You say that Febuxostat has been the only medicine that has helped. You also say that the enrollee has been on this medication since 2017. The Plan denied your request. The Plan says Febuxostat is a drug that is taken orally. The Plan says you have a medical only policy, not a Prescription Drug Plan. The Plan says drug coverage is limited to Medicare Part B covered drugs.
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 pre-approve Febuxostat, 40 mg tablet.
Benefits for Febuxostat 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 pre-approve vascular surgery treatment with an out of network (OON) provider.
You asked the Plan to pre-approve the OON vascular surgery services. You say that it is felt that the enrollee should be treated by this provider as she established care prior to the provider leaving the network. The Plan denied your request. The Plan says the documentation shows that the enrollee had a single visit and that no actual treatment was initiated. As there is no active treatment, there is no reason that her vascular surgery needs cannot be met by a network provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 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 OON vascular surgery services. Our reviewer says that the requested OON services are not considered medically reasonable and necessary as in-network providers are available. Our physician reviewer found the documentation does not demonstrate that there are unique features to this patient's condition that would require either continuity or out of network coverage. The patient has bilateral lower extremity symptoms with reflux of less than 1 second noted only on the right and the right greater saphenous vein below the knee is less than 4 mm. There is no evidence that the procedure is emergent or urgent. Care can be safely redirected to in network provider.
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 OON vascular surgery services have not been met. Therefore, we decided that the Plan does not have to pre-approve vascular surgery treatment with an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment applied to a computed tomography (CT) scan provided on December 19, 2019.
You asked the Plan to waive the copayment applied to the CT scan. You say that you should not owe anything because the doctor's office and the hospital did not tell you what it would cost or what you would owe. The Plan denied your request. The Plan says the copayment was appropriately applied the CT scan provided.
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 advanced imaging services. You have been asked to pay a $200 copayment for the CT scan. The CT scan falls within the advanced imaging services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment applied to a computed tomography (CT) scan provided on December 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on August 12, 2019 to September 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent hospital care. You say that no authorization was obtained because no one know that the insurance was changed. You need to get paid for services you provided even if no authorizations was obtained. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to 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 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 subsequent hospital care (99232) provided on August 12, 2019 to September 10, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit on December 31, 2019.
You asked the Plan to waive the copayment for an office visit. You say that this was your annual wellness visit 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 $5 copayment per primary care provider visit. You had an office visit on December 31, 2019. The record shows that you received services beyond an annual wellness visit. Therefore, you are responsible to pay the $5 copayment. You have been asked to pay a $5 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit on December 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital stay provided from
September 13, 2019 to September 28, 2019.
You asked the Plan to waive the copayments for the inpatient hospital. You say that you cannot afford to pay
these amounts. 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 $295
copayment for each day for days 1-6 for Medicare-covered hospital care and a $0 copayment for additional
Medicare-covered days.
You have been asked to pay a total of $1,770 for the inpatient hospital. The inpatient hospital falls within the
"Inpatient hospital care" benefit category. See chart below. Dates of Service Service Allowed
Amount
Copayment
per Day
Number of
Days
Member Liability
September 13, 2019 to
September 15, 2019
Inpatient care $14,591 $295 2 $590
September 24, 2019 to
September 28, 2019
Inpatient care $5,597 $295 4 $1,180
Total $1,770
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 copayments for the inpatient hospital stay provided from September 13,
2019 to September 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Human Papillomavirus (HPV) testing provided on September 11, 2019.
You asked the Plan to pay for the HPV testing. You say that the service should be covered. The Plan denied your request. The Plan says the screening can only be covered as preventative for enrollee's who are between 30-65 years old.
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 was requested for screening purposes. This test is covered once every five years for asymptomatic beneficiaries aged 30 to 65. Based on this information, the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the Human Papillomavirus (HPV) testing provided on September 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral-periapical radiographic image (D0220) and the palliative (emergency) treatment of dental pain (D9110) provided on November 21, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.
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 services provided are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral- periapical radiographic image (D0220) and the palliative (emergency) treatment of dental pain (D9110) provided on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all 4 quadrants.
You asked the Plan to pre-approve gingival irrigation. You say that you really need the dental services for teeth # 7, 8, 9, and 10. You say that you have the most problems with these teeth. You also say that a plan representative advised that you will be able to receive the crowns. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service.
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, gingival irrigation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all 4 quadrants
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on October 19, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you were told the ambulance service was in-network. 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 $250 copayment for each in- or out-of-network one-way Medicare-covered ground trip. You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance Services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance ride provided on October 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion services provided on July 25, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed services cannot be verified.
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 96413 chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. We find that CPT code 96413 is not supported in the medical record. Specifically, the medical records provided, do not properly record the time spent. Based on this information, we decided that Medicare rules for coverage have not been met.
The CPT Code definition of code 96367 is intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure). The CPT Code definition of code 96375 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure). We find that CPT codes 96367 and 96375 are not supported. An add-on code is only eligible for payment with a valid primary procedure. Because the primary procedure in this case has not met the rules for coverage, the add on codes are also not covered. Therefore, we decided that the Plan does not have to pay for the infusion services provided on July 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical complexity requiring frequent physician monitoring or intervention.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you are medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. You may benefit from PT and OT, but you do not require an intensive therapy program. This admission is not medically necessary, based on your current functional status and medical stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for myocardial perfusion imaging provided on June 22, 2019.
You asked the Plan to waive the coinsurance for myocardial perfusion imaging. You say that you disagree with the additional 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 20% coinsurance for each radiological diagnostic service. You received myocardial perfusion imaging on June 22, 2019. The total allowed amount is $650.59 and 20% of that is $130.12. You have been asked to pay the total coinsurance amount of $130.12 for myocardial perfusion imaging. Myocardial perfusion imaging 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 coinsurance for myocardial perfusion imaging provided on June 22, 2019.