Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
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 19, 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 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nuclear stress test.
You asked the Plan to pre-approve the nuclear stress test. You say that this imaging is necessary to evaluate the enrollee's condition. The Plan denied your request. The Plan says there has been no change in symptoms requiring repeat imaging at this time.
The Plan follows Medicare rules. Medicare rules say that nuclear stress testing may be covered for the indications listed 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 the nuclear stress test. Our reviewer says that the requested services are not considered reasonable and necessary based on LCD guidelines. Our
physician reviewer found based on the records the patient has coronary disease but no new or worsening symptoms on a recent clinic note and a normal nuclear stress test about 1 year ago. In this circumstance of a clinically stable patient and a recent normal nuclear stress test the documentation does not support the medical necessity for repeat nuclear stress testing about 1 year from the prior exam. Coverage criteria are not met since there are no documented covered indications for the procedure. 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 nuclear stress test have not been met. Therefore, we decided that the Plan does not have to pre-approve a nuclear stress test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that thePlan does not have to pre-approvethe Purple Mattress and adjustable bed frame (E1399).You asked the Plan to pre-approvethe Purple Mattress and adjustable bed frame. You say that the items are necessary since you have chronic back and spine issues.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 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-approvethe Purple Mattress and adjustable bed frame (E1399).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services provided to the enrollee on November 13, 2019.
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that set up and operated the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the perfusionist services provided to the enrollee on November 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share forthe total knee replacement surgery or the physical therapy visit provided from September 13, 2019 to September 17, 2019.You asked the Plan to reduce the cost share forthe total knee replacement surgery and the physical therapy visit. You say that this surgery should be considered inpatient and not an outpatient surgery.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 20% coinsurance for each covered surgery or observation room service in an in-network outpatient hospital and a $30 copayment for each covered in-network physical, occupational and speech therapy visit. You have been asked to pay a total of $2,150.98 for the total knee replacement surgery and the physical therapy visit.The total knee replacement surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The physical therapy visit falls within the "Outpatient rehabilitation services" benefit category. The record shows the surgery is considered an outpatient surgery. 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 reduce the cost share forthetotal knee replacement surgery or thephysical therapy visit provided from September 13, 2019 to September 17, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation hospital care from
May 29, 2019 through June 7, 2019.
You asked the Plan to waive the copayment for inpatient rehabilitation hospital care. You say that you are
appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan
says the claim was processed accordingly with your 2019 EOC 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).
Review of the file shows that you were admitted on May 29, 2019 and discharged on June 7, 2019. You were
asked to pay a $150 copayment per day from May 29, 2019 through June 5, 2019, days 1-8 of your inpatient
stay. There were no copayment charges from June 6, 2019, day 9 of your inpatient hospital care until your day
of discharge June 7, 2019. Per your contract there is a $150 copayment per day required for days 1-8. 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 inpatient rehabilitation hospital care from May 29, 2019
through June 7, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on September 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for wound care. You say that these services were medically necessary. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for wound care provided on September 11, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a clinical trial.You asked the Plan to pre-approve a clinical trial. You say that having a laser procedure will cure you without side effects.The Plan denied your request. The Plan says when you participate in a Medicare-approved clinical study, you do not need to get approval from the plan.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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 25, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the MRI (73721). You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the utilization of network providers is required unless the Plan pre-approves OON services in non-emergent situations.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on December 10, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that the Flexitouch system is safe and more effective than any other pump on the market. The Plan denied your request. The Plan says the requested Flexitouch brand is not clinically superior to any other brand. Medically necessary services are available within the enrollee's network.
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 provider at issue in this case is not a network provider with the Plan. 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 OON services. Our physician reviewer found that the documentation does not show that the requested out of network device is require, and otherwise medically reasonable and necessary over an in-network device. We looked at this physician's review, the file, and Medicare rules. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve OON services. Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve16 implantable neurostimulator electrodes.You asked the Plan to pre-approvethe 16 implantable neurostimulator electrodes. You say that  The Plandenied your request. The Plan says Medicare does not pay separately for L8680 because it is included in the approved procedure 63650.The Plan must follow Medicare rules. Medicare rules say that a global surgical package includes payment for supplies related to the surgery when furnished by a physician who performs the surgery. We looked at the file and Medicare rules. The records show that the plan has approved coverage for the percutaneous implantation of neurostimulator electrode array (CPT 63650).The payment for the electrodes being requested would be included in the payment for these surgical services.Therefore, we decided that the Plan does not have to pre-approve16 implantable neurostimulator electrodes
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided November 26, 2019.
You asked the Plan to waive the copayment for the vision services. You say that you had the first exam on 10/24/19 and paid the $30 copay. You were told you needed to return for more tests and there would be no copay for this visit. You cannot afford this additional copay. The Plan denied your request. The Plan says this claim was processed correctly and the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 copay for Medicare covered eye exams by a specialty care physician. You have been asked to pay $30 copay for the vision services. The vision services fall within the Vision care 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 outpatient office visit (99213) provided November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have the services lab services (CPT 0005U) provided to the enrollee on November 14, 2019.
You asked the Plan the services the services. You say that this should be paid for. The Plan denied your request. The Plan says this is not listed by the Medicare guidelines as being medically necessary.
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 the services the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the guidelines do not support the use of this test. Additionally, there are no provider medical records available for review. Without the support of the documentation, medical necessity cannot be determined. Other biomarkers (specifically, EPI, MiPS, and SelectMDx) are deemed investigational by NCCN (and presumably the others) due to lack of independent validation, false negatives, short follow-up, lack of randomized trials, lack of cut-point standardization, undetected cancers (up to 25%) with a single negative prostate biopsy, and the potential for upgrading (32%-49) that occurs in patients with Gleason 6 at biopsy. The concern implicit in the last two issues is that biomarker validations studies, which correlate biomarker test results only with initial biopsy findings, may be underestimating the risk of missing clinically significant cancer, hence the need for longer follow-up. 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 services have not been met. Therefore, we decided that the Plan does not have the services lab services (CPT 0005U) provided to the enrollee on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services provided to the enrollee on November
18, 2019.
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that set up
and operated the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says
payment for this service is the responsibility of the facility.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility for services furnished to a beneficiary.
We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the
beneficiary either directly or under arrangements made with outside providers. This service was provided via
arrangement of the facility. Payment for this service would have been included under the facility claim.
Payment to you for this service is the responsibility of the facility. Based on this information, we decided that
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan
does not have to pay for the perfusionist services provided to the enrollee on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the interim partial denture (D5820) provided on October 4, 2019.
You asked the Plan to pay the full amount for the dental service. You say that the provider and assistant advised that the service would be paid for in full by your plan. You also say that you received a bill for $260. The Plan denied your request. The Plan says that the annual maximum has been exceeded.
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 dentures are a covered service, the maximum allowance of $650 has been reached. The record shows that the Plan paid $260 towards the immediate partial denture as of February 19, 2020, thus exhausting the annual maximum of $650.
Date of Service
Billed Amount
Savings
Plan Paid
Your Responsibility
4/23/2019
$166
$81
$85
$0
7/19/2019
$88
$45
$43
$0
10/25/2019
$358
$160
$198
$0
10/4/2019
$966
$571
$324
$71
TOTAL:
$650
$71
Therefore, we decided that the Plan does not have to pay the full amount for the interim partial denture (D5820) provided on October 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a transcatheter aortic valve replacement (33361) provided on August 29, 2018.
You asked the Plan to pay for a transcatheter aortic valve replacement. You say that this was filed timely. The Plan denied your request. The Plan says the claim was not correctly submitted in time.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for a transcatheter aortic valve replacement was not filed until October 15, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a transcatheter aortic valve replacement (33361) provided on August 29, 2018.
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 lying in bed when your granddaughter found you unresponsive. You say that she called 911 and the responders found that your blood sugar was low. They treated you and after you were back to normal they asked you if you wanted to go to the hospital. You say that you declined because you sugar level was up and you felt better. You say that there was no reason to go to the hospital and that you saved your insurance money by not going. 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 on November 11, 2019. 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.