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

We decided that the Plan does not have to waive the copayment for ambulance services provided on December 20, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $270 copayment for ambulance services. You have been asked to pay a $270 copayment for ambulance services. Ambulance services fall 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 ambulance services provided on December 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided September 21, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the enrollee did not request this equipment.
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 does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, the records do not support that the prescribing physician discussed with the enrollee the medical necessity for the therapeutic continuous glucose monitor before it was ordered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical services.

You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 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 a psychiatric diagnostic evaluation with medical services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and bitewing x-rays (D0274) provided on October 20, 2020.
You asked the Plan to pay for the dental services. You say that your policy clearly states that 1 x-ray and 2 cleanings per year are covered. The Plan denied your request. The Plan says panoramic x-ray is not listed as a covered service. The Plan says bitewing x-rays are not listed as covered services either.
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 panoramic x-ray (D0330) and bitewing x-rays (D0274) provided on October 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared heating therapy provided from September 28, 2020, to December 2, 2020.
You asked the Plan to pay for infrared heating therapy. You say that you were referred to this provider. The Plan denied your request. The Plan says infrared heating therapy is denied as investigational.
The Plan must follow Medicare rules. The rules say that infrared therapy devices are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for infrared heating therapy provided from September 28, 2020, to December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered.

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 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, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lenses and lens upgrades you received on November 10, 2020.
You asked the Plan to pay for the lenses and upgrades. The Plan denied your request. The Plan says this is not a covered benefit.
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 standard frames and lenses as defined by Medicare; any upgrades are not covered. We looked at the file and the Plan's rules. The requested progressive lenses and lens upgrades are not covered under your vision plan. The Plan only covers standard frames and lenses. Based on this information, we decided that the Plan's rules for coverage of the lenses and upgrades have not been met. Therefore, we decided that the Plan does not have to pay for the progressive lenses and lens upgrades you received on November 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services.

You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because the first hospital had faulty equipment so you had to be transported to another hospital. 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 $250 copayment for ambulance services.

You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall 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 ambulance services.

We note your complaint that the first provider had faulty equipment that resulted in a second ambulance transport. Your complaint is a grievance that must be answered by the health 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 pay for a pneumatic compression device (E0675) and pneumatic appliances (E0673x2) received on November 20, 2020.
You asked the Plan to pay for a pneumatic compression device and pneumatic appliances. You say that this claim should be paid because your medical team took every precaution to avoid blood clots. The Plan denied your request. The Plan says rules for payment have not been met because the requested durable medical equipment was not used inside the home.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a pneumatic compression device and pneumatic appliances was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and pneumatic appliances (E0673x2) received on November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast biopsy (19083).

You asked the Plan to pay for the breast biopsy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this condition has a diagnosis code specific to the left side.

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 19083 is not supported in the record. Specifically, the record indicates that this procedure was rendered on the left side. Additionally, this code was billed with the LT modifier, also indicating the left side. The claim was billed with a diagnosis code specific to the right side. There is a more appropriate diagnosis code for this service. Based on this information, we decided that Medicare rules for coverage of the breast biopsy have not been met. Therefore, we decided that the Plan does not have to pay for the breast biopsy (19083).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a foot insert (L3000).
You asked the Plan to pre-approve a foot insert. You say that this item is medically necessary for your condition. The Plan denied your request. The Plan says the rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that shoe inserts and modifications are covered when they are on a shoe that is an integral part of a covered brace. We looked at the file and Medicare rules. The file indicates that you do not have brace. Based on this information, we decided that Medicare rules for coverage of a foot insert have not been met. Therefore, we decided that the Plan does not have to pre-approve a foot insert (L3000).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve out of network double-balloon retrograde enteroscopy.
You asked the Plan to pre-approve out of network double-balloon retrograde enteroscopy. You say that an in-network physician referred you for this service out of network as it is not available in network. The Plan denied your request. The Plan says that this service can be provided in network.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 out of network double-balloon retrograde enteroscopy. Our reviewer says that medical necessity has been established in this case. Our physician reviewer found for approval of double balloon enteroscopy, the enrollee meets the criteria cited by the American Society of Gastrointestinal Endoscopy (ASGE) (1), as follows: "for patients who have problems in the small intestine including bleeding, strictures, abnormal tissue, polyps, or tumors." Our reviewer says that the enrollee's condition meets the ASGE medically necessary indications for the service under review. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of out of network double-balloon retrograde enteroscopy have been met. Therefore, we decided that the Plan has to pre-approve out of network double-balloon retrograde enteroscopy.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for PancreasDx testing (81479) provided to the enrollee.

You asked the Plan to pay for PancreasDx testing (81479). You say that this testing was medically necessary. The Plan denied your request. The Plan says that medicare coverage criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

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 PancreasDx testing (81479). Our reviewer says that medical necessity has been established. Our physician reviewer found hereditary pancreatitis refers to pancreatitis with a Mendelian pattern of inheritance. The majority of cases are caused by variants in the PRSS1 gene. This disorder has an autosomal dominant pattern of inheritance with high penetrance and causes acute recurrent and chronic pancreatitis in both children and adults. Other cases of hereditary pancreatitis are caused by variants in SPINK1 (serine protease inhibitor Kazal type 1) or other genes and occasionally by multiple genetic factors. Genetic testing is medically necessary for the evaluation of patients with idiopathic acute pancreatitis, recurrent acute pancreatitis, and chronic pancreatitis after the major causes of acute pancreatitis, such as gallstone disease, heavy alcohol use, duct obstruction, and medications, have been excluded. This enrollee had recurrent attacks of acute pancreatitis for which there is no identifiable cause. The service is reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PancreasDx testing (81479) have been met. Therefore, we decided that the Plan has to pay for PancreasDx testing (81479) provided to the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the vision exam and contact lenses provided by an out of network provider.

You asked the Plan to reimburse you for the vision exam and contact lenses. You say that you did not know the provider was not a contracted provider. The Plan denied your request. The Plan says you are required to use the preferred provider for covered routine vision services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that routine vision services are not covered out-of-network.

The provider in this case is not a network provider with the Plan. The Plan had a network provider available who could have provided 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 reimburse you for these items/services. Therefore, we decided that the Plan does not have to reimburse you for the vision exam and contact lenses provided by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion Interspinous Spacer.

You asked the Plan to pre-approve the Superion Interspinous Spacer. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says this device is experimental.

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 Superion Interspinous Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its safety and efficacy.

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 Superion Interspinous Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion Interspinous Spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Bioness L300 stimulator.

You asked the Plan to pre-approve the Bioness L300 stimulator. You say that you would like reconsideration because your weakness and drop foot impact your ability to perform tasks safely and independently. The Plan denied your request. The Plan says you do not have muscle atrophy from a non-neurologic condition or a history of SCI.

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 Bioness L300 stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a FES device is only covered for use in patients with a history of a spinal cord injury (SCI) when additional requirements for coverage are met. In this case you do not have a history of a SCI.

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 Bioness L300 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the Bioness L300 stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit.

You asked the Plan to waive the copayment for an urgent care visit. You say that you should not owe a copayment for COVID-19 testing. 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 $40 copayment for each specialist visit.

You have been asked to pay the allowed amount of $22.54, which is less than the $40 copayment for an urgent care visit. An urgent care 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 urgent care visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services.

You asked the Plan to pay for the chiropractic services. You say that you cannot afford to pay for the services. The Plan denied your request. The Plan says these services are not covered.

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 at issue are not manual manipulation of the spine. Please note that you have been asked to pay a $20 copayment for each manual manipulation service, as you were made aware of. However, the office visit and physical therapy services are not covered when provided by a chiropractor. Therefore, we decided that the Plan does not have to pay for the chiropractic services.