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

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) wireless unit for the enrollee.

You asked the Plan to pre-approve the unit. You say that there is long-standing history of chronic bilateral low back pain and lumbar spondylosis. The Plan denied your request. The Plan says this is unable to be approved.

The Plan must follow Medicare rules. Medicare rules say that a TENS unit is covered if the enrollee is in an approved clinical study. 

There is no evidence an approved clinical study. Based on this information, we decided that Medicare rules for coverage of the unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) wireless unit for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment provided on August 17, 2020.
You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing except the basic lipid panel for symptomatic patients with suspected or documented cardiovascular disease.
The Plan must follow Medicare rules. Medicare rules say that cardiovascular disease screening must be reported with CPT codes 80061, 82465, 83718 or 84478. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment have not been met. Specifically, the services billed are not a medicare covered benefit. Cardiovascular Disease Screening is recognized with specific CPT codes. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment provided on August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the right shoulder brace provided on October 2, 2020.
You asked the Plan to pay for the right shoulder brace. You say that it is felt that this was billed correctly and meets medical necessity criteria. The Plan denied your request. The Plan says this was billed with an unspecified diagnosis code which is not appropriate when the side is known.
The Plan must follow Medicare rules. Medicare rules say that providers must follow ICD-10-CM guidelines when billing. The guidelines indicate that unspecified side diagnosis codes should be used when the side at issue is not identified in the medical records. In this case, the diagnosis code reported was M13.819, defined as Other specified arthritis, unspecified shoulder. The brace was clearly provided for the right shoulder. As such, the diagnosis should be specific to the condition of the right shoulder. Based on this information, we find that the billing rules have not been met with this claim. Therefore, we decided that the Plan does not have to pay for the right shoulder brace provided on October 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0480) provided on November 5, 2020, by an
OON provider.
You asked the Plan to pay for OON drug testing. You say that this service was performed in good faith. The
Plan denied your request. The Plan says this service was 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 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 drug testing (G0480) provided on November 5,
2020, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on September 4, 2020.
You asked the Plan to waive the copayment for an injection. You say that you were never told that this would cost you anything. You say that you were told that everything was taken care of. The Plan denied your request. The Plan says the correct copayment has been 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 a $250 copayment for outpatient surgery/outpatient hospital facility. You have been asked to pay a $250 copayment for an injection. An injection falls within the outpatient surgery/outpatient hospital facility 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 outpatient surgery provided by a participating provider on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99213) provided October 16, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid diagnosis code.
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 99213 is not supported in the medical record. Specifically, the diagnosis code provided on the claim did not report the correct laterality. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99213) provided October 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services provided on August 7, 2020.
You asked the Plan to waive the copayment for physical therapy services. You say that the provider should have advised you there would be two copayments for one date of service. You say that you don't agree with two copayments for one visit. The Plan denied your request. The Plan says the copayments 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 $35 copayment per Medicare-covered visit of physical therapy, occupational therapy, and speech language therapy services. A separate copayment applies to the initial evaluation and any re-evaluations. You have been asked to pay a total of $70 for physical therapy services.
Physical therapy services fall within the "Outpatient rehabilitation 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 physical therapy services provided on August 7, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance the home infusions.

You asked the Plan to waive the coinsurance the home infusions. You submitted your bills for review. You say
that you paid 100% of the charges when the infusions were delivered, or you would not have been able to
receive them. The Plan denied your request. The Plan says that the coinsurance 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 does not say in clear and accurate terms
how much you should expect to pay for home infusion procedure codes S5498 and S9501.

Procedure codes S5498 and S9501 represent a combination of professional services, supplies, and equipment
billed as a per day (per diem) charge. These codes are not valid for Medicare purposes. When these separate
items and services are combined into a single code, it cannot be determined how much of the charge represents
each individual item or service.

We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20%
coinsurance for codes that combine charges for medical supplies and professional services. The Plan contract
does not clearly say how much enrollees must pay for codes that combine charges for medical supplies and
professional services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing
information. Therefore, we decided that the Plan has to waive the coinsurance the home infusions.

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: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 23, 2020.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services
rendered on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2950) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

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 pre-approve dental services (D2950) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental consultation (D9310) provided July 13, 2020, and the endosteal implant (D6010) and bone graft (D6104).

You asked the Plan to pay for the dental consultation, endosteal implant and bone graft. You say that you were told the services would be covered. The Plan denied your request. The Plan says the claims processed correctly.

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 endosteal implant and bone graft are not among those covered under this benefit. The file also confirms that the Plan has already covered one consultation for this year. Therefore, we decided that the Plan does not have to pay for the dental consultation (D9310) and the endosteal implant (D6010) and bone graft (D6104).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 29, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 October 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laparoscopy for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says surgery for severe obesity is not covered in the presence of absolute contraindications.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found surgery for severe obesity is not covered in the presence of absolute contraindications including hepatic disease with prior documented inflammation, portal hypertension or ascites. The review has determined that the enrollee does not meet the criteria for this request.

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 to pre-approve laparoscopy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ECG provided on September 23, 2020.
You asked the Plan to pay for the ECG. You say that The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 ECG. 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 ECG provided on September 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided by an out of network (OON) provider.

You asked the Plan to pay for the surgical services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says services rendered by nonparticipating providers require prior authorization and prior authorization was not obtained.

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 surgical services provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 lab work provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on September 8, 2020.
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 must follow Medicare rules. The rules say that the CxBladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on August 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the home visit. You say that the services were medically necessary. The Plan denied your request. The Plan says there was an invalid or missing authorization.
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 home visit provided on August 4, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator (E1390) provided by an out of network (OON) provider.

You asked the Plan to pay for the oxygen concentrator. You say that you were not aware that this was an OON provider. The Plan denied your request. The Plan says prior authorization was not requested before you purchased the equipment from an OON provider.

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 oxygen concentrator (E1390) provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Arthrocentesis.

You asked the Plan to waive the copayment for the Arthrocentesis. You say that you should not have to pay three times for the same thing. The Plan denied your request. The Plan says the copayments 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 visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.

You have been asked to pay a $200 copayment for each visit for the Arthrocentesis. The total amount you owe is $600 ($200/visit x 3 visits = $600). The Arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Evidence of Coverage states the outpatient surgery copayment applies to each visit. 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 Arthrocentesis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99214) provided November 18, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you were charged a $35 copay for a visit and you shouldn't have been charged that because you were in the post-op window of 90 days for the visit. The Plan denied your request. The Plan says the claim was processed, and the correct copayment was applied per the Evidence of Coverage.
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 $35 copayment for each specialist visit. You have been asked to pay $35 copayment for the office visit. The office visit falls within the Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient office visit (99214) provided November 18, 2020.