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

We decided that the Plan does not have to waive the copayments for the office visit, lesion removal and wound repair provided on August 26, 2019 and September 5, 2019.
You asked the Plan to waive the copayments for the office visit, lesion removal and wound repair. You say that you had approval before the visits. The Plan denied your request. The Plan says a $45 copayment applies to each date of service.
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 $45 copayment for visits to specialists. Covered services include medically necessary medical care or surgery services furnished in a physician's office.
You have been asked to pay a $45 copayment for each visit.

The office visit, lesion removal and wound repair fall 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 copayments for the office visit, lesion removal and wound repair provided on August 26, 2019 and September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) provided to the enrollee on September 4, 2019.
You asked the Plan to pay for the orthosis and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
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 knee orthosis (L1833) and suspension sleeve (L2397) provided to the enrollee on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on September 9, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the services are 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 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 physician services provided to the enrollee on September 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851), lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee on August 14, 2019.
You asked the Plan to pay for the orthoses and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
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 orthoses and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeve ordered.
Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthoses and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851), lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee on August 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) services at an out-of-network facility.
You asked the Plan to pre-approve the out-of-network IRF care. You say that The Plan denied your request. The Plan says IRF care is available from participating providers in the enrollee's service area.
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 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. 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 inpatient rehabilitation facility (IRF) services at an out-of-network facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychiatric management and medication review services provided on July 10, 2019 by an out of network provider.You asked the Planto pay forthe psychiatric management and medication review 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 saythat 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 forthe psychiatric management and medication review services provided on July 10, 2019 by the out of network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing services provided to the enrollee on June 17, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that this test is rated D2 by Hayes, and is considered investigational.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 pay for the services. Our reviewer says that the services at issue in this case were medically reasonable and necessary. Our physician reviewer found NCCN Clinical Practice Guidelines in Oncology - Colon Cancer, Version 1-2020 - December 19, 2019 states that the cost effectiveness of immunohistochemistry and sometimes MSI on all newly diagnosed colorectal cancers has been confirmed and is endorsed by numerous groups. The U.S Multi-Society Task Force on Colorectal Cancer and the American Gastroenterological Association recommend universal genetic testing of tumors of all patients with newly-diagnosed colorectal cancer. The ordering oncologist documents how the genetic testing is expected to impact the care of the enrollee 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 have been met. Therefore, we decided that the Plan has to pay for genetic testing services provided to the enrollee on June 17, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to refund the copayment for services provided at an urgent care center (S9088) provided on October 20, 2019.You asked the Plan to refund the copayment foran urgent care visit. You say that you should be refunded for the urgent services copayment as they didn't do anything to help you. All they did was take your vital signs.The Plan denied your request. The Plan says an urgent care visit has a $50 copayment.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 $50 copayment for urgently needed services. You have been asked to pay a $50 copayment for an urgent care visit. This servicefalls within the urgently needed 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 refund the copayment forservices provided at an urgent care center (S9088) provided on October 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth consultation services provided on September 29, 2019 by out of network provider.You asked the Plan to pay for the telehealth consultation 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 forthe telehealth consultation services provided on September 29, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wrist hand finger orthosis (CPT Code L3807) provided on October 1, 2019.
You asked the Plan to waive the coinsurance for the orthosis. You say that you are appealing your cost-share responsibility for the services you received. 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 an orthosis on October 1, 2019. You have been asked to pay 20% coinsurance of the allowed amount for durable medical equipment. The allowed amount is $215.83. The total you owe is $43.17 ($215.83 x 20% = $43.17). 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 wrist hand finger orthosis (CPT Code L3807) provided on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 8, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the clinic visit provided on September 30, 2019.
You asked the Plan to waive the copayment for the clinic visit. You say that this was a requirement in preparation for surgery. You say that you don't remember paying a copayment for your previous surgeries. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment, after the deductible, for each in-network primary care doctor visit for Medicare-covered benefits. You have been asked to pay a $20 copayment for the clinic visit. The clinic visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the clinic visit was provided by a family nurse practitioner. 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 clinic visit provided on September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from July 14, 2019 7:49am through July 17, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient hospital care. Our physician reviewer found the review has determined that the post-stabilization care services at the non-Plan facility July 14, 2019 at 7:48am through July 17, 2019 were not medically necessary. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from July 14, 2019 7:49am through July 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve (CPT Code E2300), (CPT Code E2377), (CPT Code E2313), (CPT Code K0108) and (CPT Code E2311), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Upgraded electronics (electronic connection, expandable controller and harness) cannot be covered per Medicare rules. They are necessary when there is a medical need to control power options though the joystick. The notes do not show a medical need to control the power options through the joystick. The power options can be controlled using their own switches. These switches can be made any size without asking for a separate request. They can be made from any material without asking for a separate request. All of this can be done without the need to use the joystick to control the power features. The seat lift does not serve a primary medical purpose. This cannot be covered. More information will be given to your wheelchair provider. E2377 Expandable Controller, E2313 Expandable Controller Harness and E2311 Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are requested to control power tilt and power elevating leg rests through the joystick. The notes state that these are needed when 3 or more actuators are being used. The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three approved power options on this wheelchair (tilt and elevating leg rests), there is not a medical need to control these power options through the joystick. Documentation shows that the member's upper limb strength is 5/5 in the bilateral upper limbs with normal range of motion. Upper limb strength and function adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options. The approved power options come with their own switches. There is a request for a K0108 push handles. These do not serve a medical purpose. They cannot be covered as they are not reasonable and necessary per Medicare criteria. E2300 Seat Elevator is requested to increase independence with ADLs and transfers. Per Medicare rules, E2300 Seat Elevator is never covered as it does not serve a primary medical purpose. Therefore, we decided that the Plan does not have to pre-approve (CPT Code E2300), (CPT Code E2377), (CPT Code E2313), (CPT Code K0108) and (CPT Code E2311), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on September 6, 2019.
You asked the Plan to waive the copay for the ambulance transport. You say that you should not be responsible if the hospital your taken to can't treat you. The Plan denied your request. The Plan says that the claim processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $285 copay for each covered, one-way ambulance trip by ground or water. You have been asked to pay a $285 copay for the ambulance transport. The ambulance transport falls within the one-way ambulance trip by ground or water benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the ambulance transport provided on September 6, 2019.