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

We decided that the Plan does not have to pre-approve a power wheelchair (K0806).
You asked the Plan to pre-approve a power wheelchair. You say that this is necessary for the enrollee to be able to leave her home. The Plan denied your request. The Plan says the records indicate this is for use outside of the enrollee's home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0806).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received from November 10, 2020, to November 30, 2020.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services you received from November 10, 2020, to November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), limited oral evaluation - problem focused (D0140), and intraoral - periapical first radiographic image (D0220).
You asked the Plan to pay for the dental services. You say that you had an emergency and could not return to the plan's network. The Plan denied your request. The Plan says the requested services are not covered under your plan's 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 pay for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), limited oral evaluation - problem focused (D0140), and intraoral - periapical first radiographic image (D0220).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient admission provided from October 10, 2020, through October 14, 2020.

You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says the inpatient admission required prior authorization.

The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollee's condition can be managed safely only in the inpatient hospital setting. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the inpatient admission have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient admission provided from October 10, 2020, through October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder Detect (0012M) provided on October 27, 2020.

You asked the Plan to pay for the CxBladder Detect. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says this testing is not a Medicare covered benefit

The Plan must follow Medicare rules. Medicare rules say that non-coverage for the CxBladder assay coded as 0012M was reaffirmed by Medicare. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CxBladder Detect have not been met. Specifically, this testing is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the CxBladder Detect (0012M) provided on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist office visit provided on August 14, 2020.

You asked the Plan to waive the copay for the specialist visit. The Plan denied your request. The Plan says the copay is your financial responsibility.

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 $45 copay for each specialist in-person office visit for physician services. 

You have been asked to pay a $45 copay for the specialist visit. The visit falls within the physician 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 copay for the specialist office visit provided on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient clinic visit provided on October 15, 2020.
You asked the Plan to waive the copay for the services provided. You say that you thought follow up visits were covered. The Plan denied your request. The Plan says you are responsible for the copay.
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 copay for outpatient hospital services. You have been asked to pay a $200 copay for the services provided. The services fall within the outpatient hospital 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 copay for the outpatient clinic visit provided on October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose 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 the criteria has not been met.
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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there were no medical records provided for review. It cannot be determined with any evidence that the requested monitor is medically necessary, reasonable, or coverable. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 21, 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 procedure codes 80157, 80159, 80162, 80173, 80177 and 80201 are 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. We find that CPT codes 80157, 80159, 80162, 80173, 80177 and 80201 are not supported in the medical record. Specifically, the file shows that the testing was performed on urine specimens and not blood specimens. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care services rendered on November 16, 2020.

You asked the Plan to waive the copayment for these services. You say that you were triaged and then sent to the emergency room. The Plan denied your request. The Plan says the copayment was 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 $45 copayment for each urgent care visit.

Review of the file shows that you received urgent care services on November 16, 2020. You have been asked to pay a $45 copayment for these services. These services fall within the urgent care visit 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 urgent care services rendered on November 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from May 22, 2020, through June 1, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there are no medical records or clinical documentation from this provider for review.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the physician's services have not been met. Therefore, we decided that the Plan does not have to pay for physician's services provided from May 22, 2020, through June 1, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency room (ER) services rendered on September 9, 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 that the medical records are missing.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that medical records are missing for these services; however, the case file contains medical records for the services at issue. The Plan has not provided any documentation or Medicare rules to support that the services cannot be covered. Therefore, we decided that the Plan has to pay for the emergency room (ER) services rendered on September 9, 2020.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiological diagnostic services provided by a participating provider on November 11, 2020.
You asked the Plan to waive the copayment for radiological diagnostic services. You say that you do not agree with these copayments. 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 a $100 copayment for outpatient diagnostic tests/radiological diagnostic services/in-network. You have been asked to pay a $100 copayment for each radiological diagnostic services. The total amount you are being asked to pay is $400 ($100 x 4 tests = $400). Radiological diagnostic services fall within the outpatient diagnostic tests/radiological diagnostic services/in-network 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 radiological diagnostic services provided by a participating provider on November 11, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 29, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee was in hospice on this date of service.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided October 16, 2020.

You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says they were unable to make a decision within the 60-day time frame.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided October 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walk-in shower provided on December 7, 2020.
You asked the Plan to pay for the walk-in shower. You say that you would like reconsideration because your doctor recommended the walk-in shower for your health and safety. The Plan denied your request. The Plan says a walk-in shower does not meet the definition of durable medical equipment and is not primarily medical in nature.
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 pay for the walk-in shower provided on December 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 23, 2020 to June 30, 2020.

You asked the Plan to pay for the SNF services. You say that the enrollee was given a private room due to COVID, not by request by the enrollee or family who was given no access due to COVID. She should not be penalized to have to pay the extra cost. The Plan denied your request. The Plan says this claim was processed and the correct cost share 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. Your contract with the Plan says that there is $750 deductible and 40% coinsurance per day for out of network SNF days 1 to 100 for Skilled nursing facility (SNF) care.

You have been asked to pay $1338.55 ($750 deductible + $588.55 coinsurance). The item or service you asked the Plan to pay for falls within the benefit category Skilled nursing facility (SNF) care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible. This is the amount that you must pay out of pocket before the plan will pay their share of covered Medicare services. You must pay 40% coinsurance per day for out of network SNF days 1 to 100 for Skilled nursing facility (SNF) care. This cost sharing is a contractual obligation that had not been met at the time the SNF services was received on June 23, 2020 to June 30, 2020. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 23, 2020 to June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the lab services. You say that determining the optimal surgery is in the best interest of the enrollee. The Plan denied your request. The Plan says the enrollee's Plan requires utilization of network providers, and authorization for certain 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 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 the lab services provided on July 30, 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 a Group 3 power wheelchair and accessories.
You asked the Plan to pre-approve a Group 3 power wheelchair and accessories. You say that the enrollee needs a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says the enrollee lives in a SNF and is capable of limited ambulation with access to various accessories to assist with ambulation.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Records show that a Group 3 power wheelchair and accessories is being requested for use in a SNF. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on October 1, 2020.

You asked the Plan to pay for the orthosis. You say that the progress note documents a detailed history. The Plan denied your request. The Plan says the enrollee did not receive a video or telephonic visit by the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of durable medical equipment (DME) may not contact an individual by telephone regarding the furnishing of a covered item.

We looked at this physician's review, the file, and Medicare rules. In this case, the records show that the enrollee was contacted via an unsolicited phone call regarding provision of the item at issue. As such, no payment may be made for this item. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rabies vaccine provided on November 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that no authorization is needed. The Plan denied your request. The Plan says 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. There are no records to show that the services were urgent or emergent. 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 rabies vaccine provided on November 8, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PCA3/KLK3 testing.

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered investigational.

The Plan must follow Medicare rules. Medicare rules say that PCA3 testing covered only when all biopsies in previous encounter(s) are negative. 

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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the coverage criteria has not been met, as you have not had a prior negative biopsy. 

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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve PCA3/KLK3 testing.