Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 office visit provided on January 22, 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 Freestyle Libre Continuous Glucose Monitor Sensor (K0553).
You asked the Plan to pre-approve the CGM sensor. You say that the sensor is medically necessary. The Plan denied your request. The Plan says rules for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 CGM sensor. Our reviewer says that coverage criteria is not met. Our physician reviewer found the record does not show the enrollee is insulin dependent. 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 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor Sensor (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a submucous resection (30140) provided on September 3, 2019.
You asked the Plan to pay for the submucous resection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the operative report did not include documentation of a partial or complete submucous resection inferior turninate, any method.
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 30140 is submucous resection inferior turbinate, partial or complete, any method . We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the submucous resection. Our reviewer says that CPT code 30140 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not indicate that a resection was performed during this procedure. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the submucous resection have not been met. Therefore, we decided that the Plan does not have to pay for a submucous resection (30140) provided on September 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs provided on January 3, 2020.You asked the Plan to waive the coinsurance for the Part B drugs. You say that this coinsurance is a financial hardship.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 Medicare Part B covered chemotherapy drugs and other Part B covered drugs.You have been asked to pay $23.24, which is 20% of the allowed amount for the Part B drugs. The allowed amount is $116.24 ($116.24 x 20% = $23.24). The Part B drugs fall 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 Part B drugs provided on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic testing provided on April 17, 2019.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were provided in the absence of signs or symptoms indicating a need for the tests.
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 testing at issue in this appeal was requested solely for screening purposes as part of a pre-operative exam. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the diagnostic testing provided on April 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 23, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 the laboratory services are not supported in the medical record. Specifically, the submitted
medical records indicate that the services were administered by a health care provider other than the billing
health care provider. Based on this information, we decided that Medicare rules for coverage of the laboratory
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services
provided on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) and cone beam CT capture and
interpretation (D0365) provided on January 9, 2020 by an out of network dentist.
You asked the Plan to pay for the dental services. You say that you presented your ID card at the time of
service. You also say that you feel the provider should have known they were out of network. The Plan denied
your request. The Plan says the provider in this case is not a network provider. The Plan says dental benefits
are limited to the dental plan network. The Plan also says you did not call to confirm network status prior to
obtaining these 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, dental services that you receive out of
network are not covered. The Evidence of Coverage clearly states that dental benefits are limited to the dental
plan network. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) and cone
beam CT capture and interpretation (D0365) provided on January 9, 2020 by an out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye examination provided on December 6, 2019.
You asked the Plan to waive the copayment for the vision care. You say that you thought this was covered in full. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the medical eye examination provided on December 6, 2019. This was not a routine eye examination; therefore, you are asked to pay a $40 copayment for the medical eye exam. 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 medical eye examination provided on December 6, 2019.
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
3, 2019.
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397). You say that the
orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services
were not met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis and
suspension sleeve provided on October 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vimpat tablets.
You asked the Plan to pre-approve Vimpat tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Vimpat tablets are not covered under the enrollee's Medicare Part B benefit.
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 pre-approve Vimpat tablets.
Benefits for Vimpat tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram provided on December 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 electrocardiogram provided on December 7, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient consultation services (99255) provided on December 5, 2019.
You asked the Plan to pay for the inpatient consultation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99255 has a status code if I which is not valid for Medicare purposes.
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 99255 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99255 has a status code of I. This means that CPT code 99255 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the inpatient consultation services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient consultation services (99255) provided on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Speech generating device (E2510).
You asked the Plan to pre-approve the speech generating device. You say that the item is medically necessary and only available out-of-network. The Plan denied your request. The Plan says the Prentke Romich Accent 800, Touch Chat, Indi Tobii Dynavox, and Indi 7 Tobii Dynavox are comparable devices and are available from in-network providers.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a Speech generating device (E2510).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for teeth # 29 and 31.You asked the Plan to pre-approve the dental services. You say that the enrollee has a defective existing bridge for teeth # 29 to # 31 with opened margins. You also say that the crowns are not needed due to there being a cavity under the crowns.The Plan denied your request. The Plan says there is no evidence of pathologic destruction of the teeth beneath the current bridge warranting replacement crowns. The Plan also says that the medical necessity criteria for the crowns is not met.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. The Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the crowns are not medically necessary. Our physician reviewer found the present bridge appears intact and functional with no radiographic evidence of recurrent caries or defects. The reviewer found that the provided documentation does not support the criteria for coverage for replacement crowns for teeth # 29 and 31. Therefore, the crowns are not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for teeth # 29 and 31.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cataract removal provided on October 15, 2019 and October 29, 2019.
You asked the Plan to waive the coinsurance for cataract removal. You say that you were informed the copayment was included in the surgery cost. You say that there should be no charge for post-operative surgery visits. The Plan denied your request. The Plan says the claim reprocessed to only apply 10% coinsurance.
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 10% of the cost for each in-network, Medicare-covered ambulatory surgical center visit. You have been asked to pay a total of $15.58, which is 10% of the allowed amount for the cataract removal. The allowed amount is $155.58 ($155.58 x 10% = $15.58). The cataract removal falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 cataract removal provided on October 15, 2019 and October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 20, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sure Injection 140mg/ml for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug that falls under the Part D benefit.
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 pre-approve Repatha Sure Injection 140mg/ml for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve Pegfilgrastim-cbqv for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this can be approved if the chemotherapy drug has a medium or high risk of causing a low white blood cell count.
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 the drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has lung cancer treated with carboplatin, which has a high risk of causing a low white blood cell count. The documentation support that the documentation support that Pegfilgrastim-cbqv is medically reasonable and necessary for the enrollee. The documentation support that Pegfilgrastim-cbqv is safe and effective. 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 drug have been met. Therefore, we decided that the Plan has to pre-approve Pegfilgrastim-cbqv for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 23, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their
denial The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 office visit provided on August 23, 2019 by an
out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for these services dressings and/or debridement (16020)
provided on July 25, 2019.
You asked the Plan to pay for these services the dressings and/or debridement. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted
medical records do not indicate that dressings and/or debridement of partial-thickness burns, initial or
subsequent; small was performed or applied.
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 16020 is dressings and/or debridement of partialthickness
burns, initial or subsequent; small (less than 5% total body surface area).
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the dressings and/or debridement. Our reviewer says that
CPT code 16020 does not meet criteria for billing or reimbursement consideration. Our reviewer found no
documentation was submitted to support that dressings and/or debridement was done on this date of service. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the dressings and/or debridement have not been met. Therefore, we decided that
the Plan does not have to pay for these services dressings and/or debridement (16020) provided on July 25,
2019.