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

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on September 20, 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 Healthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) remains not supported.
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 definition of HCPCS G0483 is: "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." Medicare rules also say that a physician order must be present for labs to be covered. We find that HCPCS code G0483 is not supported in the medical record. Specifically, there was no physician order or medical records stating exactly what 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 September 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ensure purchased on November 9, 2019.You asked the Plan to pay for the Ensure. You say that you would like reimbursement.The Plan denied your request. The Plan says that this is not covered by the plan.The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the Ensure is an OTC item.Therefore, we decided that the Plan does not have to pay for the Ensure purchased on November 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the remaining amount for the surgical extraction (D7210) of tooth # 30 provided on September 19, 2019.You asked the Plan to pay the remaining amount forthe dental service. You say that you had a surgical extraction. You say that you see this provider because he helps you afford the dental care that you need. You say that the Plan does not make an effort to properly communicate with you based on your disabilities. You also say that the dental coverage is lousy.The Plan denied your request. The Plan says the provider in this case is not a network provider with the Plan. The Plansays you are responsible for any difference between the Maximum Allowable Fee (MAF) and the amount the provider bills you for the 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 and extractions are a covered service, the provider in this case is out of network. The record shows that thePlan paid 100% of the allowable rate under Medicare ($122). For services received out of network, you are responsible for the difference between what the provider charges ($330) and the maximum allowable rate ($122).Therefore, we decided that the Plan does not have to pay the remaining amount forthe surgical extraction (D7210) of tooth # 30 provided on September 19, 2019.Your complaint about the Plan not communicating with you properly based on your disability and the dental coverage being lousyare not valid appeals for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair and accessories to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe out-of-network services. You say that you are in-network with the plan.The Plan denied your request. The Plan says there are in-network providers who can supply this type of wheelchair.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requestedprovider 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. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approvea power wheelchair and accessories to be provided by an out of network (OON) provider
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical laparoscopy provided on April 17, 2019.
You asked the Plan to pay for the surgical laparoscopy. You say that the services that were performed in the
hospital at the time of the enrollee's visit were emergent. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
enrollee's terminal condition.
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 surgical laparoscopy provided on April 17, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the specialist office visit provided on September 9, 2019. You asked the Plan to waive the copayment for the specialist office visit. You say that this was a follow-up appointment after surgery and according to the Evidence of Coverage, there is no copayment for post-op appointments. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
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. The plan did not submit medical records to support that these services were provided on an outpatient basis and not as an outpatient observation period. Also, there is no provision in the contract about global periods. Therefore, the plan has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment for the specialist office visit provided on September 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on August 26, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 forthe laboratory services provided on August 26, 2019by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the kidney function panel rendered to you on August 31, 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 was not billed correctly.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 9 represents a code for which the concept of a professional/technical component does not apply. The provider submitted a claim for procedure code 80069-26. This code has a PC/TC indicator of 9 and a professional component does not apply. Therefore, we decided that the Plan does not have to pay for the kidney function panel rendered to you on August 31, 2019.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the CT scan provided on October 10, 2019. We decided that the Plan does not have to waive the copayment for the observation stay and CT scan provided on October 11, 2019.
You asked the Plan to waive the copayment for the observation stay and CT scans. You say that you were informed the CT scans would be free if they were done at the hospital. You say that you are appealing the charges. The Plan says that the copayments applied correctly.
We decided that the Plan has to waive the copayment for the CT scan provided on October 10, 2019.
The medical records show that the CT scan on October 10, 2019 was provided before you were admitted to observation status. This means that the CT scan is included in the emergency department services. Therefore, we decided that the Plan has to waive the copayment for the CT scan provided on October 10, 2019.
We also decided that the Plan does not have to waive the copayment for the observation stay and CT scan provided on October 11, 2019.
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 $210 for each Medicare-covered outpatient hospital observation stay at a hospital facility and 200 for each type of Medicare-covered diagnostic radiology service including MRI, CT Scans, Nuclear Scans and PET scans, per date of service.
You have been asked to pay a $210 copayment for the observation stay and $186.16 for the CT scan provided on October 11, 2019, which is less than the standard $200 copayment. Therefore, we decided that the Plan does not have to waive the copayment for the observation stay and CT scan provided on October 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not beenmet.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased September 6, 2019.
You asked the Plan to pay for the hearing aids. You say that you are requesting review of the claim and reimbursement. The Plan denied your request. The Plan says the services are covered benefits but the benefit limit has been exceeded.
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 any amount over the $1,000 benefit allowance for hearing aids. You have been asked to pay $1916. The plan has a $1,000 allowance for hearing aids every 3 years. The claim was submitted for $2915.46. The plan paid $1000 towards this claim. Any charges above the benefit limit is your responsibility. The hearing aids falls within the Routine Hearing 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 pay for the hearing aids purchased September 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay 70% of the total bill for the periodic oral evaluation (D0120), the prophylaxis (D1110), the bitewing x-ray (D0272), and the initial periapical x-ray (D0220) provided from September 5, 2019 to October 7, 2019 by the out of network provider.You asked the Plan to pay 70% of the total bill for the dental services. You say that there is no provision in the documentation that gives the Plan the right to establish the negotiated rate. You say that the Plan should pay 70% of the actual bill and my total responsibility should be 30% of the total bill which is exactly stated in the Evidence of Coverage.The Plan denied your request. The Plan says when using an out of network provider, you are responsible for a 30% coinsurance.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, services that are received out of network are subject to a 30% coinsurance. Cost sharing amounts are a contractual obligation you agreed to when you enrolled in the Plan's dental coverage Therefore, we decided that the Plan does not have to pay 70% of the total bill for the periodic oral evaluation (D0120), the prophylaxis (D1110), the bitewing x-ray (D0272), and the initial periapical x-ray (D0220) provided from September 5, 2019 to October 7, 2019 by the out of network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre.
You asked the Plan to pre-approve a Freestyle Libre. You say that the requested item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs and related supplies are covered when specific criteria is 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 pre-approve a Freestyle Libre. Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee is noted to have diabetes for which she takes both oral medication and a set dose of long-acting insulin. The enrollee does not check her blood sugars. The enrollee does not use the results of blood sugar testing to self-adjust insulin doses multiple times a day (i.e. follow a sliding scale). Therefore, the use of a CGM is not shown to be medically necessary or reasonable. 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 Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Cxbladder testing provided on August 13, 2019.
You asked the Plan to pay for Cxbladder test. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because tests with no relation to a medical diagnosis of disease for the health of an enrollee are not a covered benefit.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for Cxbladder test by the enrollee's in-network treating urologist  The record shows that the provider ordered this testing as medically necessary based on a non-screening indication. The file does not show that the plan provided notice that Cxbladder test would not be covered. Under Medicare rules, this means Cxbladder test is considered approved by the plan. Therefore, we decided that the Plan has to pay for Cxbladder testing provided  on August 13, 2019.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve three additional occupational therapy visits in the home health setting (beyond the one visit originally approved).You asked the Plan to pre-approvethe additional occupational therapy visits. You say that the enrollee is awaiting a transplant and has been benefitting from these regular home health visits and needs them to continue.The Plan denied your request. The Plan says that it was originally decided that all home health was to be discontinued but on review it was felt that physical therapycould continue but occupational therapy should be discontinued.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. The Plan failed to forward this case to uswithin the expedited time frame. This should have been received by us in December 2019 but was not received until February 20, 2020. The file indicates that the enrollee had been receiving ongoing home health therapy. While the Planseems to have retrospectively approved four continued visits which were originally denied in November 2019, it was silent regarding the four requested occupational therapy visits of which three were denied. The Plan has not forwarded any home health records from this time period upon which a determination of whether the three additional occupational therapy visits were medically necessary.  As such, the denial is not substantiated.Therefore, we decided that the Plan has to pre-approvethree additionaloccupational therapy visits in the home health setting (beyond the one visit originally approved)
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0080) from
Florida to Minnesota.
You asked the Plan to pay for the ambulance transportation. You say that it was necessary to return home and
the providers in Florida did not take your insurance. The doctors also recommended the return home. You had
to pay out of pocket $6350 and you request reimbursement. The Plan denied your request. The Plan says this
service is not a covered benefit.
The plan follows Medicare rules. The rules say that Medicare pays for air or ground ambulance services only if
the enrollee's medical condition is such that transportation by means other than an ambulance would not be
appropriate. The rules say that Medicare only pays for air or ground transport to the nearest facility that meets
the enrollee's medical needs if the enrollee cannot be treated by the originating facility.
The enrollee was transported from Florida to a lower level of care in Minnesota. There is no indication that a
lower level of care facility in Florida could not meet the enrollee's medical needs. The plan says that lower
level of care was available in Florida. Based on this information, we decided that Medicare rules for coverage
of the ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay
for the non-emergency ambulance transportation (A0080) from Florida to Minnesota.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve towelettes (A9286) and wound cleanser (A6260).
You asked the Plan to pre-approve the towelettes and wound cleaner. You say that you feel that the supplies should be covered The Plan denied your request. The Plan says wound cleansers are non-covered under the surgical dressing benefit. The towelettes are non-covered because they are personal care/convenience item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve towelettes (A9286) and wound cleanser (A6260).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (S9328) provided January 15, 2019 to February 7, 2019.
You asked the Plan to pay for the infusion services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is not valid for Medicare reimbursement.
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. Specifically, per CMS HCPCS guidelines, "S" codes are not payable by Medicare. Based on this information, we decided that Medicare rules for coverage of the infusion services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services (S9328) provided January 15, 2019 to February 7, 2019.