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

We decided that the Plan does not have to pay for an LSO (L0650) provided on October 1, 2020.
You asked the Plan to pay for an LSO. You say that the requested item is medically necessary for the enrollee. The Plan denied your request. The Plan says no video or telephonic visit by the ordering physician was documented to warrant the code billed.
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 pay for an LSO. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was lower back pain. The available documentation in the case file does not support that the requested LSO was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the LSO was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an LSO have not been met. Therefore, we decided that the Plan does not have to pay for an LSO (L0650) provided on October 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI on November 23, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you did not have this service because you are claustrophobic. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment per provider, per date of service for complex radiology. You have been asked to pay a $200 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the MRI was performed. 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 MRI on November 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 10, 2020.
You asked the Plan to pay for laboratory services. You say that pathology can be considered at the in-network benefit if the ordering provider is in-network. You say that you will accept the in-network rate and not hold the patient responsible for the difference. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 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 laboratory services provided by an out-of-network provider on December 10, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 inpatient hospital services. Our reviewer says that inpatient hospital services are medically necessary and reasonable for the enrollee. The patient was not making progress with physical therapy and in the judgement of the therapist, it had failed. The patient meets the other criteria and has Obstructive Sleep Apnea, which requires close observation in an inpatient setting. Our physician reviewer found that the enrollee's condition meets Medicare criteria for inpatient hospital services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital services have been met. Therefore, we decided that the Plan has to pre-approve inpatient hospital services for 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 completely pay for the dental cleaning (D1110) and unspecified
preventative procedure (D1999) provided on November 30, 2020.
You asked the Plan to completely pay for the dental services. You say that you do not feel the Plan has paid
everything they should have for your dental benefits. The Plan denied your request. The Plan says the
unspecified preventative procedure is not a service that is covered by Medicare or by the Plan's supplemental
dental benefit. Also, these services were provided by an out-of-network provider. When you receive services
out-of-network, the Plan will pay their maximum allowed amount for services. However, you may be billed by
the provider for any amount greater than the payment made by the Plan. The Plan allows $40 for a dental
cleaning. This amount was paid to the provider, and you are responsible for any amount the provider bills
above the $40.
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 unspecified preventative
procedure is not among those covered under this benefit. Additionally, the Plan has provided documentation
showing that the cleaning was provided out-of-network and the Plan has paid the allowed rate for this service.
Unlike in-network providers, out-of-network providers have not agreed to bill for only this negotiated rate. Per
the contract, you are responsible for the amount an out-of-network provider charges above this allowed rate.
Therefore, we decided that the Plan does not have to completely pay for the dental cleaning (D1110) and
unspecified preventative procedure (D1999) provided on November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on July 6, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied code 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 HCPCS code. We find that HCPCS code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 (HCPCS G0482) provided to the enrollee on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services and wound care supplies provided on December 8, 2020 and December 9, 2020.
You asked the Plan to pay for the physician's services and wound care supplies. 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 physician's services and wound care supplies provided on December 8, 2020 and December 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from December 1, 2020, to December 2, 2020.
You asked the Plan to pay for the self-administered drugs. You say that your denial letter did not list the type or the amount of self-administered drugs. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
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 pay for the self-administered drugs provided from December 1, 2020, to December 2, 2020.
Benefits for the self-administered drugs 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the 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 had network providers 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 pay for these items/services.
Medicare rules also say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 80069 has a bundled relationship with code 80053 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 3, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. 

The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services were not urgent, emergent or 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 had network providers 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 pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 22, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diabetic supplies provided on November 13, 2020.

You asked the Plan to waive the coinsurance for the diabetic supplies. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received diabetic supplies on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.

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 20% coinsurance for Diabetes self-management training, diabetic services and supplies.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received diabetic supplies on November 13, 2020. These supplies were diabetic services and supplies. You have been asked to pay a 20% coinsurance for the diabetic supplies, totaling $78.48. The diabetic supplies fall within the Diabetes self-management training, diabetic 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 the diabetic supplies provided on November 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Invega Sustenna (J2426).
You asked the Plan to pre-approve Invega Sustenna. You say that this drug is to be administered by a physician. You also say that the drug will not be supplied by the physician. The Plan denied your request. The Plan says this drug is not covered under Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Invega Sustenna (J2426).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on January 21, 2021.

You asked the Plan to waive the copayment for the laboratory services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received laboratory services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $30 copayment per day, per provider, for Medicare-covered lab services.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received laboratory services on January 21, 2021. You have been asked to pay a $30 copayment for the laboratory services. The laboratory services fall within the Outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 12, 2020.

You asked the Plan to pay for the physician's 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 physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on November 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 4, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you have never had to pay before. You say that you don't think the bill is right. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment per one way trip for emergency and non-emergency ambulance services. You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport 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 transport provided on October 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on December 16, 2020.
You asked the Plan to pay for an x-ray. You say that this is supported in the records. The Plan denied your request. The Plan says this requires a modifier.
The Plan must follow Medicare rules. Medicare rules say that if the same physician or other supplier entity does not furnish both the technical component (TC) and professional component (PC) of a diagnostic service, the professional interpretation of a diagnostic test must be separately billed with modifier -26 by the interpreting physician. We looked at the file and Medicare rules. The record shows that the billing physician provided only the professional interpretation of the test at issue. This service requires modifier -26, which was not billed on the claim. Based on this information, we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wig (A9282) provided on October 15, 2020.
You asked the Plan to pay for a wig. You say that you lost all of your hair due to the trauma of being attacked by a hawk. The Plan denied your request. The Plan says rules for payment have not been met.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, though the Plan does offer a supplemental benefit which would provide coverage for a wig, this benefit is available only in cases of hair loss due to chemotherapy. The case record does not indicate that your hair loss is due to chemotherapy. Therefore, we decided that the Plan does not have to pay for a wig (A9282) provided on October 15, 2020.