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

We decided that the Plan does not have to pay forCPT code 95937 provided on November 1, 2019.You asked the Plan to pay forCPT code 95937. You say that youwould like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says CPT code 95937 is not supported.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 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.We find that CPT code 95937 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring.Therefore, we decided that the Plan does not have to pay forCPT code 95937 provided on November 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) and comprehensive periodontal evaluation - new or established patient (D0180) provided on January 7, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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. Your records show that you had a comprehensive periodontal evaluation and full mouth series films and both services have already been approved for payment by the Plan within the last calendar year. We are unable to approve your request for payment for the additional comprehensive periodontal exam and full mouth series films. Your Plan states, for one periodontal exam every three years and one full mouth series films every five years. Therefore, we decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) and comprehensive periodontal evaluation - new or established patient (D0180) provided on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next EZ Test Strips.
You asked the Plan to pre-approve Contour Next EZ Test Strips. You say that this is what the enrollee is used to. The Plan denied your request. The Plan says this is not a preferred brand.
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred as long as the above listed conditions are met. We looked at the file and Medicare rules. The documentation does not show that an alternate brand is medically necessary. The Plan has indicated that they have approved a 90-day transition period on the requested brand. Based on this information, we decided that Medicare rules for coverage of Contour Next EZ Test Strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour Next EZ Test Strips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy provided from February 6, 2020 to February 25, 2020.You asked the Plan to waive the copayments for the physical therapy. You say that you feel the enrollee should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says the enrollee received physical therapy on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per the enrollee's contract with the Plan.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 $35 copayment for Outpatient rehabilitation services. We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee had physical therapy services on February 6, 2020, February 11, 2020, February 12, 2020, February 19, 2020, February 21, 2020, and February 25, 2020. The enrollee has been asked to pay a $35 copayment for each physical therapy visit, totaling $210. The physical therapy visits fall within the Outpatient rehabilitation services benefit category. 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 copayments for the physical therapy provided from February 6, 2020 to February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 30, 2019 to
November 5, 2019 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 October 30, 2019
to November 5, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided from September 3, 2019 to October 10, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says these services can be rendered within the Plan's network. These services do not fall within the exception of emergency or urgently needed services and a prior authorization is required.
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 nurse practitioner services provided from September 3, 2019 to October 10, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve10 Home Healthcare visits.You asked the Plan to pre-approve the Home Health visits. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says these services are not medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 Home Health visits. Our reviewer says that the records do not show that skilled nursing services are required to effectively provide treatment, care and/or services in order to improve your conditionor to establish/perform a maintenance program to maintain your condition or prevent deterioration. Our physician reviewer found the records do not show that evidence that ongoing skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. The documentation does not support that home health aide services are reasonable and necessary to the treatment of your illness or injury by the skilled professional staff.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 Home Health visits have not been met.Therefore, we decided that the Plan does not have to pre-approve10 Home Healthcare visits.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit and electrocardiogram provided on September 7, 2019.
You asked the Plan to pay for the physician services. You say that you were out of town when you felt increase heart palpitations. You say that your friend recommended you see the provider in this case. You say that you never thought to go to the emergency room or an urgent care. The Plan denied your request. The Plan says that the services were not urgent or emergent. The Plan says that authorization was not obtained before you received the services.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. 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 physician services. Our reviewer says that the services were medically necessary. Our physician reviewer found you experienced new palpitations and blood pressure elevation while out of the service area. You could not have foreseen requiring the services prior to leaving your service area. The reviewer found that the records indicate that the care provided was medically necessary. Therefore it would not have been medically reasonable to delay the services until the you returned to your Plan's service area. 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 physician services have been met. Therefore, we decided that the Plan has to pay for the office visit and electrocardiogram provided on September 7, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient surgery services rendered on
January 20, 2020.
You asked the Plan to waive the deductible for these services. You say that the charges are a financial hardship.
The Plan denied your request. The Plan says the deductible was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible for your covered medical services.
The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery benefit
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750
deductible for your covered medical services. This cost sharing is a contractual obligation that had not been
met at the time these services were received on January 20, 2020. Therefore, we decided that the Plan does not
have to waive the deductible for the outpatient surgery services rendered on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 6, 2019 to
December 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the office visit (99214). You say that you would like reconsideration because the
services rendered were medically necessary. The Plan denied your request. The Plan says the member is
enrolled in an HMO plan and required to use network providers for these types of 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 for the medical services provided on November 6,
2019 to December 6, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on January 7, 2020.You asked the Plan to pay forthese 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 forthe drug testing rendered on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6534.
You asked the Plan to pre-approve the compression stockings. You say that you need the stockings. The Plan denied your request. The Plan says there is no evidence of a qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6534 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6534.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe requestedphysician's services.You asked the Plan to pre-approve the physician's 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 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment the specialist visit provided on December 19, 2019.You asked the Plan to waive the copayment the specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received services at a specialist's office on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (suchas copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment per visit if performed at a specialist's office.We looked at the file, the Plan contract and Medicare rules. The file shows that you received services at a specialist's office on December 19, 2019. You have been asked to pay a $35 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment the specialist visit provided on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a motorized scooter (K0806). You asked the Plan to pre-approve a motorized scooter. You say that the enrollee needs this because she cannot ambulate very far without fatigue and oxygen.The Plan denied your request. The Plan says the requested scooter cannot be used for activities within the enrollee's home.The Plan follows Medicare rules. Medicare rules say that for a power mobility device to be coveredall of the above basic criteria (A-C) must be met.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 a motorized scooter. Our reviewer says that the requested power mobility device is not medically necessary at this time. Our physician reviewer found the enrollee does not meet the criteria in that she is independent in all her ADLs (toileting, feeding, dressing, grooming, and bathing) and transfers. Her upper extremity strength is functional as described above and yet PT documented that she is not safe using a walker, cane or a manual wheel chair. The document does not address whether or not she can self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day. She has sufficient upper extremity function and should be able to manage a manual wheel chair.Physical therapy notes do not show that the requested scooter can be used for MRADLs within her recreational vehicle (RV) living space.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a motorized scooter have not been met.Therefore, we decided that the Plan does not have to pre-approvea motorized scooter (K0806).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract surgery provided on December 17, 2019.
You asked the Plan to pay for the cataract surgery. 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 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 cataract surgery provided on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cast rendered on January 6, 2020.You asked the Plan to pay for these services. You say that you needed the cast to ensure your dentures would fit.The Plan denied your request. The Plan says the services are not a covered 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 dental cast rendered on January 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the head rendered on January 17, 2020.You asked the Plan to waive the copayment for these services. You say that you were told that the services would be covered.The Plan denied your request. The Plan says the copayment was 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 $225 copayment for each advanced imaging service (eg, MRI, CT, and PET scans, nuclear medicine, and stress tests). Review of the file shows that you received a CT scan of the head on January 17, 2020. Per the contract with the Plan, there is a $225 copayment for each advanced imaging service (eg, MRI, CT, and PET scans, nuclear medicine, and stress tests). This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $93.07. Given that the allowed amount was less than the $225 copayment, you have been asked to pay $93.07 for these services.Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the head rendered on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered on March 7, 2019 and May 21, 2019.
You asked the Plan to pay for these services. You say that you were not told you had to buy from a Medicare provider. The Plan denied your request. The Plan says the provider is not Medicare-certified.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the physician services rendered on March 7, 2019 and May 21, 2019.