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

We decided that the Plan does not have to pre-approvea power scooter for the enrollee.You asked the Plan to pre-approvea power scooter. You say that the longer the enrollee does not have a scooter, the accessible to fall increases.The Plan denied your request. The Plan says there is no evaluation to show the device meets the enrollee's needs.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. In this case, there is insufficientmedicalrecords to show that the enrollee hasa mobility deficit that impairs participation in MRADLs, hiscondition cannot be improved by a walker, cane or manual wheelchair, or that hecan safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea power scooter for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's vision services provided on October 25, 2019.You asked the Plan to pay for the physician's vision services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 servicesat 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 physician's vision services provided on October 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 27, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on June 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full night titration study (95811).
You asked the Plan to pre-approve the titration study. You say that the titration study is medically necessary. The Plan denied your request. The Plan says the enrollee can use an auto-titrating CPAP at home.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the titration study. Our reviewer says that the requested ervices are not considered medically reasonable and necessary in this case. Our physician reviewer found the current standard of care, when obstructive sleep apnea is diagnosed on a home sleep study, is to initiate PAP therapy at home using auto-titrating CPAP, unless there are clinical reasons why this should not be done. If this fails then an attended titration study may become 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 the titration study have not been met. Therefore, we decided that the Plan does not have to pre-approve a full night titration study (95811).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extra-spinal chiropractic manipulative treatment (98943) provided on October 11, 2019.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denialas the chiropractic treatment has been working; however,you will require several more visits.The Plan denied your request. The Plan says these services are not a covered benefit by Medicare or your health Plan.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 record shows that the services at issue are not covered by Medicareor the health plan.Therefore, we decided that the Plan does not have to pay forthe extra-spinal chiropractic manipulative treatment (98943) provided on October 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on May 1, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing rendered to enrollee on May 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forblood pressure monitoring provided by on October 23, 2019.You asked the Plan to pay forblood pressure monitor or blood pressure monitoring during an ambulance transport.You say that the Plan should pay this claim.The Plan denied your request. The Plan says ambulatory blood pressure monitoring is only covered for suspected white coat hypertension and performed at least 24 hours.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 A4670 is automatic bp monitor, dial.We find that CPT code A4670 is not supported in the medical record. Specifically,the enrollee did not receive a blood pressure monitor during transport and blood pressure monitoring in an ambulance is not separately payable. Based on this information, we decided that Medicare rules for coverage of blood pressure monitor or blood pressure monitoring during an ambulance transport. have not been met.Therefore, we decided that the Plan does not have to pay forblood pressure monitoring provided on October 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on October 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory testing. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says that the ordering provider is not a network provider. The Plan also says that the services could be provided in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The ordering provider is not a network provider either. 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 laboratory testing provided on October 24, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean outpatient spinal procedure for the enrollee.You asked the Plan to pre-approvethe surgery. You say that this is medically necessary.The Plan denied your request. The Plan says this is not medically 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 the surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found three level vertebroplasty is considered experimental. More conservative measures are also needed.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 surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvean outpatient spinal procedure for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the OON physical therapy. You say that you have been seeing this provider
and feel that they offer a special level of care that you require. The Plan denied your request. The Plan says
there are physical therapy providers in your area who can assume your care. You may continue to see this OON
provider under your POS benefit but there is no network deficiency to warrant in-network coverage for this
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 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
the physical therapy services to be provided 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 on August 12, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 service 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 laboratory services provided on August 12, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay foran ultrasound (76981) provided on November 19, 2019.You asked the Plan to pay for the ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the Medicare rule for payment of this claim has not been met as the professional interpretation of a diagnostic test must be separately billed with modifier-26 by the interpreting physician.The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the technicalcomponent (TC) of radiology services furnished to hospital patients.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Specifically, the claim does not include the appropriate 26-modifier to indicate the professional component of this service. Therefore, we decided that the Plan does not have to pay for an ultrasound (76981) provided on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on April 27, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing rendered to enrollee on April 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on November 5, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that these services were medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are in-network providers available for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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 foran office visit provided on November 5, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Part B injection provided on January 25, 2019.You asked the Plan towaive the coinsurance forthe part B injection. You say that this amount is too high for the injection. You say you are on social security and you already have other bills. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs. You have been asked to pay $1,623.46 which is 20% of the allowed amount for the part B injection. The allowed amount is $8,117.28. ($8,117.28 x 20% = $1,623.46). The part B injection falls 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 forthe Part B injection provided on January 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments forthe tendon injections provided on May 13, 2019 and June 3, 2019.You asked the Plan to reduce the copayments forthe tendon injections. You say that you were not in hospital observation and that you have paid much less for these services in the past. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $250 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $250 copayment for each of the tendon injections. The tendon injections fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the tendon injections areconsidered surgical procedures.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 reduce the copayments forthe tendon injections provided on May 13, 2019 and June 3, 2019.Our decision is only about the 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe debridement of subcutaneous tissue provided on September 25, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe wound care. You say that the services were provided to the enrollee at the request of the medical director.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says the services were not urgent or emergent in nature.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The requesting provider is not a network provider either. 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 forthe debridement of subcutaneous tissue provided on September 25, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological medical examination on August 7, 2019.You asked the Plan to waive the copayment for the ophthalmological medical examination. You say that that you and the enrollee have never received and invoice for services in the past and that everything has always been covered. The Plan denied your request. The Plan says the correct copayment has been applied to the claim.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copayment for vision care, Medicare-covered exam to treat an eye condition.The enrollee has been asked to pay a $45 copayment for the ophthalmological medical examination. The ophthalmological medical examination falls within the vision care, Medicare-covered exam to treat an eye condition.This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ophthalmological medical examination provided on August 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive metabolic panel and complete blood count with automated differential of white blood cell count provided on September 18, 2019 by an out of network (OON) provider.You asked the Plan to pay for the laboratory testing. You say that the provider is an independent laboratory that relies on the referring physician to obtain prior authorization.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the services were not urgent or emergent in nature. The Plan also says the services could be provided in network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. 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 comprehensive metabolic panel and complete blood count with automated differential of white blood cell count provided on September 18, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).