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

We decided that the Plan does not have to pay for the x-ray services provided on October 11, 2019 by an out of network (OON) provider.You asked the Plan to pay for the x-ray 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 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 x-ray services provided on October 11, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 30, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrocentesis services coded 20611 provided on
November 25, 2019.
You asked the Plan to pay for the arthrocentesis 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.
In this case, the CPT Code Manual definition of code 20611 is arthrocentesis, aspiration and/or injection, major
joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording
and reporting.
We find that CPT code 20611 is not supported in the medical record. Specifically, the documentation did not
support arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial
bursa); with ultrasound guidance, with permanent recording and reporting. Based on this information, we
decided that Medicare rules for coverage of the arthrocentesis services have not been met. Therefore, we
decided that the Plan does not have to pay for the arthrocentesis services coded 20611 provided on November
25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for facedown recovery equipment (E1399) purchased November
13, 2019.
You asked the Plan to pay for the facedown recovery equipment. You say that you had called in advance of
your surgery date and was told that you could pre-pay for this medical equipment and then be reimbursed. The
Plan denied your request. The Plan says this item is not covered
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 facedown recovery equipment (E1399) purchased November 13,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on September 4, 2019 and September 6, 2019.You asked the Plan to pay for the subsequent nursing facility care. 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 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 subsequent nursing facility care provided on September 4, 2019 and September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 14, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the specialist copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $40 copayment for each specialist visit. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 4, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (E0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
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 lumbar-sacral orthosis provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 7, 2020 by an out of network (OON) provider.
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 services were rendered by an out-of-network provider without 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 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 January 7, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for provider visit. You say that the provider depends upon the facility staff to verify eligibility and obtain the proper authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 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 January 9, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pay for replacement bulb/lamp for ultraviolet light therapy system (A4633x6). We decided that the Plan does not have to pay for replacement bulb/lamp for ultraviolet light therapy system (A4633x2).
You asked the Plan to pay for Replacement bulb/lamp for ultraviolet light therapy system (A4633x8). You say that you are appealing the denial for ultra violet bulbs for ultraviolet therapy for psoriasis. The Plan says that this request exceeds the allowable of 6.
We decided that the Plan has to pay for replacement bulb/lamp for ultraviolet light therapy system (A4633x6).
We also decided that the Plan does not have to pay for replacement bulb/lamp for ultraviolet light therapy system (A4633x2).
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code A4633 is 6. You billed for 8 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of Replacement bulb/lamp for ultraviolet light therapy system (A4633x6) have been met as the MUE allowed is 6. The remaining 2 exceeds the MUE and does not meet the rules for coverage. Therefore, we decided that the Plan does not have to pay for Replacement bulb/lamp for ultraviolet light therapy system (A4633x2).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says the information
submitted does not meet the Plan's medical necessity guidelines for coverage.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Gelsyn-3. Our reviewer says that the
coverage criteria for this injection are not met. Our physician reviewer found there is no documentation of a
contraindication to a first line viscosupplement injection drug treatment. Our reviewer also found that a
Monovisc injection should be tried first.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gelsyn-3 (J7328).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the anti-tremor orthotic glove system.
You asked the Plan to pre-approve the anti-tremor orthotic glove system. You say that you need
this orthotic because of your medical condition. The Plan denied your request. The Plan says the orthosis is still
in the development stage
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 Readi-Steadi anti-tremor orthotic
glove system. Our reviewer says that this orthotic is not medically reasonable and necessary. Our physician
reviewer found the documentation does not support that the anti-tremor glove and elbow orthoses
are medically reasonable and necessary for the enrollee in this case. It has not been adequately demonstrated in
clinical trials that anti-tremor glove and elbow orthoses are both safe and effective. Anti-tremor glove and
elbow orthoses would be considered experimental/investigational at this time.
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 anti-tremor orthotic glove system have not been met.
Therefore, we decided that the Plan does not have to pre-approve the Readi-Steadi anti-tremor orthotic glove
system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee required minimal assistance with upper body dressing, transfers, and grooming. The enrollee required moderate assistance with lower body dressing. The enrollee required supervision for toileting. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however, the enrollee's functional level does not require or indicate that this therapy must be in an IRF with an intensive level program. 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.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional routine transportation trips.
You asked the Plan to pre-approve ten (10) additional routine transportation trips. You say that you have no other way to get to your appointments. The Plan denied your request. The Plan says that rides above the benefit limit are not covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of ten (10) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to approve coverage above the benefit maximum of ten (10) routine transportation. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the eyeglasses you received on January 17, 2020.
You asked the Plan to pay more for the eyeglasses. You say that the glasses should be covered in full. The Plan denied your request. The Plan says the benefit amount was exceeded.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $250 allowance every year. We looked at the file and the Plan's rules. The records show that you received eyeglasses on January 17, 2020. The plan paid $250 toward the eyeglasses. You are responsible for the amount in excess of the $250 allowance. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay more for the eyeglasses you received on January 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance services (A0429) provided on November 11, 2019 while outside of the United States.
You asked the Plan to pay for the ambulance services. You say that you had an accident while traveling out of the country. There were no options to find an in-network provider at the time and you do not understand why the claims are not covered. The Plan denied your request. The Plan says services provided outside of the United States are not covered.
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. You required emergency ambulance services while outside of the United States. The health plan contract on page 39, specifically says that the plan does not cover urgently needed services or any other care if you receive the care outside of the United States. 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 emergency ambulance services (A0429) provided on November 11, 2019 while outside of the United States.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided from January 23,
2020, to January 27, 2020.
You asked the Plan to pay for the services provided. You say that the enrollee improved in all areas of function
The Plan denied your request. The Plan says detail is lacking how the unique skills of PT can further the
enrollee's progress.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 pay for the services provided. Our physician
reviewer found that the physical therapy provided on the dates of service at issue are not generally accepted as
specific and effective therapy for the enrollee's condition. There is no demonstration that the unique skills of a
professional therapist were required to safely and effectively provide treatment, that the services can be safely
and effectively performed only by a therapist, or under the supervision of a therapist for dates at issue in this
case.
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 services provided have not been met. Therefore, we decided that the Plan
does not have to pay for the physical therapy services provided from January 23, 2020, to January 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from April 12, 2019 through May 4, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. You state you were told this would be 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 shows that you were admitted on April 12, 2019 and discharged on May 4, 2019. You were asked to pay a $320 copayment per day from April 12, 2019 through April 16, 2019, days 1-5 of your inpatient stay. There were no copayment charges from April 17, 2019, day 6 of your inpatient hospital care until your day of discharge May 4, 2019. Per your contract there is a $320 copayment per day required for days 1-5. 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 inpatient hospital care from April 12, 2019 through May 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient services you received on
January 13, 2020.
You asked the Plan to waive the copayment. You say that you shouldn't have to pay anything. The Plan denied
your request. The Plan says you are responsible for the cost share.
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 at an outpatient hospital facility.
Review of the file shows that you were provided outpatient surgery service on January 13, 2020. You have
been asked to pay a $275 copayment for the services. 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 copayment for the outpatient services you received on January
13, 2020.