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

We decided that the Plan does not have to pay for train of four testing (95999) provided on May 7, 2019.

You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other services.

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 95955 is not supported in the medical record.  Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures.  Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on May 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 16, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that this doctor has been your optometrist for over 20 years and has been treating your glaucoma since 2012. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.

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 16, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the seat lift chair purchased on April 18, 2019.
You asked the Plan to reimburse you for the seat lift chair. You say that you ordered the lift chair from the facility because the price was lower than local dealers. The Plan denied your request. The Plan says you did not have a physician order at the time of purchase and the facility is not a Medicare certified supplier.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or provider who has opted out of the program except in cases involving emergencies or urgently needed care. Also, Medicare does not cover the upholstered portion of a seat lift chair. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the facility. This provider has opted out of the Medicare program. The file shows that the facility entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to reimburse you for the seat lift chair purchased on April 18, 2019.
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 at the veterinarian clinic getting your dog an exam when you began to feel dizzy and started to pass out. An ambulance was called but you declined transportation because you were feeling better. You say that you did not want the ambulance called in the first place and they only checked your blood pressure and made sure you were okay. You believe that you should not be charged for the response services. 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 April 29, 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.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Cinqair.
You asked the Plan to pre-approve Cinqair. You say that the Cinqair is medically necessary. The Plan denied your request. The Plan says that rules for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Cinqair. Our reviewer says that the Cinqair is medically necessary. Our physician reviewer found documentation supports the enrollee has elevated eosinophilic levels, is on maintenance Advair, Singulair and rescue albuterol. Records further support she has utilized oral steroids with good effect. The documentation supports medical necessity for the use Cinqair for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cinqair have been met. Therefore, we decided that the Plan has to pre-approve Cinqair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power wheelchair (K0813).You asked the Plan to pre-approve the power wheelchair. You say that the item is medically necessary.The Plan denied your request. The Plan says the power wheelchair is not medically necessary.The Plan follows Medicare rules. Medicare rules say that a power wheelchair is covered if the beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided.The file shows that there is no evidence of a home evaluation to determine if the beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a Group 1 power wheelchair (K0813).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health aide services for bathing.You asked the Plan to pre-approvehome health aide services. You say that the enrollee was not in hospice at the time of request.The Plan denied your request. The Plan says Original Medicare is responsible for services while under hospice.The Plan must followMedicare rules. The rules say that custodial care is not covered.The file shows that bathing services were requested for the enrollee. We looked at the file, and Medicare rules. Bathing is considered custodial care, which is not covered by Medicare. Also, the records show that the enrollee's hospice ended on January 15, 2020. The services in question were requested for carebefore the end of that month. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.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 pre-approvehome health aide services for bathing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on September 4, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on September 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the glucagon hydrochloride injection provided on October 10, 2019.
You asked the Plan to waive the coinsurance for the glucagon hydrochloride injection. You say that per your benefits, you should not be liable for this amount. The Plan denied your request. The Plan says 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 clearly says that you must pay 20% coinsurance for Part B drugs, including chemotherapy drugs.
You have been asked to pay $80.11, which is 20% coinsurance of the allowed amount for the glucagon hydrochloride injection. The allowed amount is $400.53 (20% x $400.53 = $80.11). The glucagon hydrochloride injection falls within the "Medicare Part B prescription drugs" 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 glucagon hydrochloride injection provided on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Zoster (shingles) vaccine (90750) and administration (90471) provided on October 18, 2019.You asked the Plan to pay fora shingles vaccine. You say that your pharmacist said this would be covered.The Plan denied your request. The Plan says this vaccine is only covered by Medicare Part D.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine.Therefore, we decided that the Plan does not have to pay fora Zoster (shingles) vaccine (90750) and administration (90471) provided on October 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 74176) provided to the enrollee on October 12, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

We looked at the file and Medicare rules. The documentation provided shows that the service in question was billed on a duplicate claim as one previously paid by the plan for the date of service in question. 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 the services (CPT 74176) provided to the enrollee on October 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay fornursing facility care provided on July 15, 2019 by an out of network (OON) provider.You asked the Plan to pay fornursing facility care. You say that you would this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the membersought out non-emergent services by a non-participation 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 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 fornursing facility care provided on July 15, 2019by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pay for home health services provided from July 16, 2019 to July 31, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis is not a Medicare-certified provider.Medicare rules say that services must be provided by providers who are enrolled in the Medicare program.The requested provider in this case isnot a Medicare certified provider. 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 Plandoes not haveto pay forhome health services provided from July 16, 2019 to July 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the requested orthotics are medically necessary for the enrollee. You say that the enrollee suffers from severe posterior tibial tendon dysfunction and the orthotics are meant to provide arch support. You say that the requested orthotics will help prevent the need for a brace or more aggressive surgery in the future. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on September 7, 2019.You asked the Plan to pay forthe hearing aids. You say that you want to request reimbursement of $600 for your purchase of hearing aids per the benefit provided by the plan.The Plan denied your request. The Plan says the maximum benefit has been exhausted.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 there is a$600 allowance for hearing aids every 3 years. You have been asked to pay $2149. You have requested the plan to reimburse $600 for the hearing aids. The plan sent reimbursement on October 7, 2019 for the hearing aids. The full cost of the remaining hearing aid balance is your responsibility. The hearing aids falls within the Routine Hearing Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to pay forhearing aids purchased on September 7, 2019
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Low Dose Computed Tomography scan (LDCT) for lung cancer screening (G0297).
You asked the Plan to pre-approve an LDCT scan for lung cancer screening. You say that the service is necessary. The Plan denied your request. The Plan says that the enrollee is 78 years old. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that an LDCT scan for lung cancer screening is covered when specific criteria are met. We looked at the file and Medicare rules. Specifically, the enrollee was within the covered age range at the time the scan was originally requested. Additionally, the information that was missing could have been obtained from the network provider prior to issuing the denial, which also was issued while the enrollee was in the covered range. Based on this information, we decided that Medicare rules for coverage of an LDCT scan for lung cancer screening have been met. Therefore, we decided that the Plan has to pre-approve a Low Dose Computed Tomography scan (LDCT) for lung cancer screening (G0297).
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an x-ray and a specialist office visit provided on February 26, 2019.
You asked the Plan to waive the copayments for an x-ray and a specialist office visit. You say that you feel like this was a waste of time and don't agree with the additional charges. The Plan denied your request. The Plan says the correct copayments have 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 an $8 copayment for outpatient diagnostic tests/x-rays and a $45 copayment for physician/practitioner services/specialist. You have been asked to pay an $8 copayment for an x-ray and a $45 copayment for a specialist office visit. The total amount you are being asked to pay is $53 ($45 + $8 = $53). An x-ray falls within the outpatient diagnostic tests/x-rays benefit category and a specialist office visit falls within the physician/practitioner services/specialist benefit category. Since these services were provided to you the correct copayment has been applied. 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 copayments for an x-ray and a specialist office visit provided on February 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided to the enrollee on September 6, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that you would like the bill to paid by the Plan.The Plan denied your request. The Plan says that copayments are a member's contractual obligation.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $50 copayment for covered ambulance services. The enrollee has been asked to pay a $50 copayment for the ambulance transport. The ambulance transport falls within the covered ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation theenrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance transport provided to the enrollee on September 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an incision and insertion of a chest wall respiratory sensor electrode (64568 and 0466T).You asked the Plan to pre-approve the incision and insertion of a hypoglossal nerve stimulator. You say that you have sleep apnea and have had trouble using a continuous positive airway pressure device. The Plan denied your request. The Plan says this request is not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the incision and insertion of a hypoglossal nerve stimulator have not been met. Specifically, per Local Coverage Article: Billing and Coding: Category III CPT? Codes (A56195), insertion of a chest wall respiratory sensor electrode (0466T) is not covered as it is not considered medically reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve an incision and insertion of a chest wall respiratory sensor electrode (64568 and 0466T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to you on January 28, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says procedure code 95999 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, there is no documentation to support train of four testing forcode 95999. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Please note that the Plan states that you will not be held liable for these services. Therefore, we decided that the Plan does not haveto pay forthe services rendered to you on January 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on August 22, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. 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 for these services. The Plan says that there are in-network providers 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 foran office visit providedon August 22, 2019 by an out of network (OON) provider.