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

We decided that the Plan does not have to pay for the continuous therapeutic glucose monitor and supplies provided October 19, 2020.

You asked the Plan to pay for the continuous therapeutic glucose monitor and supplies. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says coverage criteria have not been met.

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 record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, the medical records do not indicate that the provider discussed the medical necessity of the requested item with the enrollee. 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 continuous therapeutic glucose monitor and supplies provided October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for repairs for shoe holders codes with K0108 and arm rests coded with K0108.

You asked the Plan to pay for repairs for shoe holders codes with K0108 and arm rests coded with K0108. You say that these repairs are medically necessary. The Plan denied your request. The Plan says the requested codes for these items are incorrect.

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 K0108 is Wheelchair component or accessory, not otherwise specified.

We find that CPT code K0108 is not supported in the medical record. Specifically, both the arm rest and the shoe holders have codes that should be billed separate from the code K0108 used for miscellaneous items. Based on this information, we decided that Medicare rules for coverage of shoe holders codes with K0108 and arm rests coded with K0108 have not been met. Therefore, we decided that the Plan does not have to pay for repairs for shoe holders codes with K0108 and arm rests coded with K0108.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.

You asked the Plan to pre-approve Zilretta. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Zilretta. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found you have right rotator cuff tendonitis. The requested use is considered an experimental/investigational use of this steroid preparation. It is FDA approved for a single use in the knee. There are several other steroid compounds that have support in the literature. Therefore, you do not meet criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to
pre-approve Zilretta.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) received December 15, 2020.

You asked the Plan to pay for the intraoral - complete series of radiographic images. You say that the requested service should be covered by the Plan. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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 intraoral - complete series of radiographic images (D0210) received December 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 14, 2020.

You asked the Plan to waive the copayment for the ambulance transport. You say that the doctor treating you contacted the ambulance service, and the explanation of benefits states you do not have to pay. You say that the claim should be reevaluated. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for each covered, one-way ambulance trip by ground or water. 

You have been asked to pay a $300 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 14, 2020.
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 December 18, 2020.

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 December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) received January 4, 2021.

You asked the Plan to pay for the crown. You say that you were not aware that your plan changed and that the requested service would not be covered. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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 crown - porcelain/ceramic (D2740) received January 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a molecular pathology procedure (81479) provided on January 26, 2021, by an OON provider.

You asked the Plan to pay for a molecular pathology procedure. You say that the requested procedure was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for OON care have not been met.

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 a molecular pathology procedure (81479) provided on January 26, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the injection provided on January 26, 2021.

You asked the Plan to waive the copay for the services provided. You say that the injection is not surgery. The Plan denied your request. The Plan says the cost share is correct for the services billed.

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 $325 copay for Medicare-covered outpatient hospital facility surgery. for outpatient surgery. 

The file shows you received a carpal tunnel injection in your wrist. The injection is considered a surgical service. You were charged $258.73 for the service. Because the amount is less than the $325 copay, you were charged the lesser amount. The services fall within the outpatient surgery 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 injection provided on January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided March 26, 2019.

You asked the Plan to pay for automatic external defibrillator. You say that the claim denied for timely filing. Requesting forgiveness in this matter. Please reprocess. The Plan denied your request. The Plan says this claim was submitted past the timely filing limitation.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for automatic external defibrillator was not filed until January 6, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided March 26, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on September 5, 2020.

You asked the Plan to pay for the anesthesia services. You say that the enrollee was not enrolled in hospice at the time the service was rendered to the enrollee. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on September 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 12, 2021.

You asked the Plan to pay for the ambulance 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 January 12, 2021. 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 provided on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic imaging of optic nerve of eye (92133) provided on January 13, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the diagnostic imaging of optic nerve of eye. You say that the requested service should be paid for by the Plan. The Plan denied your request. The Plan says criteria for obtaining out-of-network coverage were not met.

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 diagnostic imaging of optic nerve of eye (92133) provided on January 13, 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 the psychiatric diagnostic evaluation (90791) psychotherapy, 45 minutes (90834) provided on November 5, 2020 to November 25, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychiatric services. You say that you followed proper procedures and got a doctor's referral to Mental Health and you refuse to pay these bills. The Plan denied your request. The Plan says the information submitted does not support the billed service. 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 psychiatric diagnostic evaluation (90791) psychotherapy, 45 minutes (90834) provided on November 5, 2020 to November 25, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 17, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an insertion of a penile prosthesis (54400).

You asked the Plan to pre-approve an insertion of a penile prosthesis. You say that the requested procedure is a necessity for you. The Plan denied your request. The Plan says the requested procedure is not reasonable and necessary.

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 an insertion of a penile prosthesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that treatment of your erectile dysfunction with Viagra was not effective. No other treatments for erectile dysfunction have been tried. The penile prosthesis insertion is not medically reasonable and necessary. The medical records indicate that no trials of vacuum erection devices, intraurethral medications, or intracavernous injections have been tried.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an insertion of a penile prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve an insertion of a penile prosthesis (54400).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on January 14, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 to you by an out-of-network provider on January 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the surgery services provided on February 15,
2021.

You asked the Plan to waive the copay for the services provided. You say that the procedure was to correct a
complication of a previous cataract surgery. The Plan denied your request. The Plan says the claim processed
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 $275
copay for surgery in an ambulatory surgical center.

You have been asked to pay $243.09 for the services provided. Because the amount is less than the $275 copay,
you were charged the lesser amount. The services fall within the outpatient surgery 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 surgery services provided on February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 17, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you cannot go home in your current medical
condition. The Plan denied your request. The Plan says your rehab needs are not complex, and you do not need
to see a rehab doctor 3 times a week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our physician reviewer found
that you were admitted to the acute care hospital for surgical treatment of a hip fracture after a fall. Your
medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple
therapies in an intensive rehab therapy program. While the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.