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

We decided that the Plan does not have to pay for the thoracic-lumbar-sacral orthosis (L0457) provided March 12, 2021.

You asked the Plan to pay for the orthosis. You say that this enrollee requested services utilizing access to telemedicine from the physician of their choice in an effort to address COVID-19 concerns. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician and the provider is not a Medicare certified DME supplier and is not eligible to receive payment.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.

The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the proof of delivery did not include an order number or details to corroborate the delivery ticket. The delivery ticket submitted did not include the carrier's tracking number. Also, the provider is not a Medicare certified DME supplier. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the thoracic-lumbar-sacral orthosis (L0457) provided March 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic or therapeutic agent injections.
You asked the Plan to pre-approve diagnostic or therapeutic agent injections. You say that the services are
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria
has not been met.
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria.
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 diagnostic or therapeutic agent
injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found there
is magnetic resonance imaging (MRI) evidence of a screw loose at C4 without surgical follow-up completed
and this can be a pain generator. No recent physical therapy or other conservative therapy is noted. The
requested service is not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of diagnostic or therapeutic agent injections have not been met. Therefore, we
decided that the Plan does not have to pre-approve diagnostic or therapeutic agent injections.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a
participating provider on March 4, 2021

You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this should not have
any copayment. 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 $275
copayment for outpatient surgery/preferred.

You have been asked to pay a $275 copayment for a diagnostic colonoscopy. Evidence was provided that
showed polyps were found and removed. The rules say that, if during the course of the screening colonoscopy,
a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic
procedure classified as a colonoscopy with biopsy or removal should be billed. You can find this rule on page
67 of the Plan's 2021 EOC. A diagnostic colonoscopy falls within the outpatient surgery/preferred 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 a diagnostic colonoscopy provided by a
participating provider on March 4, 2021
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the
services are medically necessary. Our physician reviewer found you do not have documented skilled nursing
needs. You do have documented skilled therapy needs. Your weight bearing status has been advanced. Daily
skilled services are required to establish a maintenance program or to prevent deterioration of your condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing
facility (SNF) care.

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 pay for the gym membership fee purchased in 2021.
You asked the Plan to pay for a gym membership fee. You say that you have submitted additional proof for
reimbursement. The Plan denied your request. The Plan says for payments made in 2021, the Plan cannot
approve reimbursements under the 2020 benefit year.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits
for each calendar year.
The Plan's rules for coverage of gym benefits have not been met because you must submit your request for
reimbursement for 2021 separately from your 2020 request for reimbursement. You received a full $122.33
reimbursement for 2020. The remaining requested number of payments for 2021 must be submitted for the
2021 Wellness Allowance Benefit. Therefore, we decided that the Plan does not have to pay for the gym
membership fee purchased in 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 23, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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. 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 services provided by an out-of-network provider on February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 7, 2021.
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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for an exercise class (S9451) for the 2020 benefit allowance.
You asked the Plan to pay an additional amount for an exercise class. You say that your wife was reimbursed with the same proof of payment for $150. The Plan denied your request. The Plan says they are unable to approve your request for additional reimbursements for the 2020 Wellness Allowance Benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract provides reimbursement for gym benefits only when the Wellness Allowance reimbursement form and proof of payment are submitted. The Plan contract also says the Plan reimburses up to $150 each calendar year towards your cost for membership in a health club or facility. The services at issue in this appeal are gym benefits. You requested a $138 reimbursement for exercise classes and acupuncture services for benefit year 2020. You have been reimbursed $18 for the exercise classes, six classes at $3 each. You have also received an $80 reimbursement for two (2) acupuncture services.
You were reimbursed a total of $98 for these services. We find that the Plan does not have to reimburse you an additional $40 as you have requested. The documentation within the record shows that you only provided proof of payment for $98 worth of services towards the allotted benefit allowance. Therefore, we decided that the Plan does not have to pay an additional amount for an exercise class (S9451) for the 2020 benefit allowance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the office visit and spine x-rays provided from October 7, 2020, to November 11, 2020.

You asked the Plan to pay for the office visit (99203) and spine x-rays (72100). You say that this chiropractor was the nearest to your home and has helped you to walk once again. The Plan denied your request. The Plan says the office visit and x-ray are excluded from Medicare coverage when performed by a chiropractor.

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 reimburse you for the office visit and spine x-rays provided from October 7, 2020, to November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical access to an implant body (second stage implant
surgery) (D6011) provided January 19, 2021.

You asked the Plan to pay for the surgical access to an implant. You say that you do not agree with the cost
because the benefit booklet says that dental services are covered. The Plan denied your request. The Plan says
this service is not covered under your dental services.

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
surgical access to an implant body (second stage implant surgery) (D6011) provided January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth specialist service provided on February 23, 2021.
You asked the Plan to waive the copayment for the telehealth specialist service. You say that this was just a phone call for test results, and you do not think it is fair that you had no choice in the matter. The Plan denied your request. The Plan says the Medicare allowed amount is less than your copayment so you are only responsible for the lesser amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for Physician Services. You have been asked to pay a $38.23 copayment for the telehealth specialist service. The telehealth specialist service 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 copayment for the telehealth specialist service provided on February 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on November 10, 2020.
You asked the Plan to pay for physical therapy. 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
physical therapy. 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 physical therapy provided on November 10, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency department visit (99285) hospital observation service (G0378) provided February 25, 2021 to February 26, 2021.

You asked the Plan to waive the copayment for the hospital services. You say that you are questioning this copayment as the hospital discharged without explanation. The doctor insisted that they needed you to stay so they can perform a procedure then they changed their mind and decided not to perform it. The Plan denied your request. The Plan says the claim was processed with the correct copayment 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 $225 copayment for outpatient hospital observation services.

You have been asked to pay $225 copayment for the hospital services. The hospital services fall within the Outpatient hospital observation 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 emergency department visit (99285) hospital observation service (G0378) provided February 25, 2021 to February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site (D7953) and the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) received March 16, 2021 from the out-of-network provider.

You asked the Plan to pay for the dental services. You say that the Plan should pay for the requested services. The Plan denied your request. The Plan says there is no coverage for services received from an out-of-network provider.

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 when they are received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site (D7953) and the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) received March 16, 2021 from the out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided by provided from February 14, 2021, through February 18, 2021.
You asked the Plan to pay for the self-administered drugs. You say that he could not have given himself a medication due to his inability to lift his arms. You say that it was impossible for him to administer medication or eat and the denial should be reviewed. The Plan denied your request. The Plan says the service is not covered by the Plan.
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 by provided from February 14, 2021, through February 18, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administered the 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 a multiplex respiratory viral panel with 12-15 targets (87633) provided on May 13, 2020.

You asked the Plan to pay for a multiplex respiratory viral panel with 12-15 targets. You say that this testing was related to COVID-19. The Plan denied your request. The Plan says this testing is not covered.

The Plan must follow Medicare rules. Medicare rules say that multiplex polymerase chain reaction (PCR) respiratory viral panels of 6 or more pathogens are non-covered.

We looked at the file and Medicare rules. The testing at issue targeted more than 6 pathogens and is non-covered. Based on this information, we decided that Medicare rules for coverage of a multiplex respiratory viral panel with 12-15 targets have not been met. Therefore, we decided that the Plan does not have to pay for a multiplex respiratory viral panel with 12-15 targets (87633) provided on May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that providers must report services correctly. Procedures should be reported with the Current
Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the
Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for
Medicare Services, Chapter I(A).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic visit (99203) you had on February 18, 2021.

You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is not a covered service.

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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic visit (99203) you had on February 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy session (90837) provided on April 2, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for psychotherapy session. You say that you believe you do not owe the past bill of $230.00. This doctor is not in your service plan. Please make all adjustments that are necessary. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 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 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 individual psychotherapy session (90837) provided on April 2, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic shoes (A5507, A5512) provided November 27, 2020.
You asked the Plan to pay for the diabetic shoes. You say that the diabetic shoes were medically necessary. The Plan denied your request. The Plan says the shoes were provided by a provider that does not participate in the Medicare program. Payment cannot be made for these items.
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 practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for diabetic shoes (A5507, A5512) provided November 27, 2020.