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

We decided that the Plan does not have to waive the copayment for the ultrasounds.

You asked the Plan to waive the copayment for the ultrasounds. You say that you have been getting ultrasounds and mammograms for years at no cost, but you were charged for ultrasounds this year. The Plan denied your request. The Plan says the copayments 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 $110 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).

You have been asked to pay a $110 copayment for each ultrasound. The total amount you owe is $220 ($110/ultrasound x 2 ultrasounds = $220). The ultrasounds fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 ultrasounds.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin b-12 and folic acid testing.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the benefit limits have been exceeded.

The Plan must follow Medicare rules. Medicare rules say that Vitamin b-12 testing and folic acid assays are each covered up to 3 times per year.

We looked at the file and Medicare rules. The records show that the Plan paid for Vitamin b-12 testing and folic acid assays 3 times each during the 2020 calendar year. This means that the requested services exceed the benefit limit set by LCD L34914. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the vitamin b-12 and folic acid testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that you were told that no referral was needed. The Plan denied your request. The Plan says 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 is not a network provider with the Plan and the services were not referred by a network provider. The services were not urgent or emergent, nor were they approved in advance.

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 had network providers available who could have provided 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 an office visit (99214) provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lung cancer screening with low dose computed tomography (LDCT).
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 pre-approve the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found your smoking history (six pack years, quit more than 50 years ago) places you in a low-to-moderate risk category. This does not meet the eligibility for this screening.
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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve lung cancer screening with low dose computed tomography (LDCT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a orthoses (L1833, L2397).

You asked the Plan to pay for the knee orthosis. You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the documentation does not support the items billed.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery. The documentation does not include an itemized delivery record showing the items were delivered to the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a orthoses (L1833, L2397).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on February 26, 2020, by an
OON provider.
You asked the Plan to pay for an office visit. You say that you did not realize that you did not have an
approved authorization before treating the patient. The Plan denied your request. 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 services were not referred by a network provider or rendered in a participating
facility. The services were not urgent or emergent, nor were they approved in advance.
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 had network providers
available who could have provided 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 an office visit (99214) provided on February 26,
2020, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for X-rays provided on November 13, 2020.
You asked the Plan to waive the copayment for X-rays. You say that you paid the $20 copayment for the visit and disagree with the additional charges for the X-rays. 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 $10 copayment for X-rays. You received two X-rays on November 13, 2020. Therefore, you are responsible to pay a $10 copayment per each X-ray. The total amount you owe is: $20. You have been asked to pay the total copayment amount of $20 for X-rays. X-rays fall within the outpatient diagnostic tests and therapeutic services and supplies 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 X-rays provided on November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME provided on October 15, 2019.
You asked the Plan to pay for the DME. You say that due to mobility and trouble accessing a computer, you are asking the Plan reconsider payment. The Plan denied your request. The Plan says you did not file the claim within one year after the date the services were furnished.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the DME was not filed until December 4, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the DME provided on October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

Explanation of decision
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (CPT code L0650) provided on September 14, 2020.
You asked the Plan to pay for the orthosis. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee did not receive video or telephonic visit by the ordering physician in order to warrant the code(s) billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Review of the enrollee's claim history was conducted and showed that there was not a claim for the ordering physician. You did not present any medical records showing that the prescribing physician ever saw the enrollee. The ordering physician is not listed in this enrollee's history of claims. There were no services found for the enrollee billed on the service date presented in the documents. The Plan has concluded the claim should be denied due to it appears this enrollee did not receive video or telephonic visit by the ordering physician in order to warrant the code(s) billed. Furthermore, there are no claims on file with the ordering physician listed in the enrollee's claims history 2019-present. Therefore, we are upholding the original denial. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (CPT code L0650) provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a supply allowance for a therapeutic continuous glucose monitor.
You asked the Plan to provide supply allowance for a therapeutic continuous glucose monitor (K0553). You say that the enrollee's fingers are black and bruised from finger stick testing. The Plan denied your request. The Plan says criteria is not met for a CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a supply allowance for a therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hearing exam (92550).

You asked the Plan to waive the copayment for the hearing exam. You say that this should have been covered in full by a supplemental Plan benefit. The Plan denied your request. The Plan says this provider does not participate in that Plan benefit. Therefore, this copayment was applied correctly as a hearing exam provided by a specialist.

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 each diagnostic hearing exam provided by a specialist.

You have been asked to pay a $45 copayment for the hearing exam. The hearing exam was provided by a specialist who does not participate in the Plan's supplemental program. 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 hearing exam (92550)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing (CPT code(s) 81162, 81406 and 81479) provided to the enrollee on July 18, 2019.
You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. 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 laboratory testing have not been met. The information received does not show the enrollee has a personal history of cancer. Therefore, we decided that the Plan does not have to pay for the laboratory testing (CPT code(s) 81162, 81406 and 81479) provided to the enrollee on July 18, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0151, G0156, G0157, G0299, Q5001).

You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not correctly billed.

The Plan must follow Medicare rules. Medicare rules say that home health claims are paid on a 30-day period of care (on or after January 1, 2020).

We looked at the file and Medicare rules. In this case, the provider billed for a 60-day period of care. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (G0151, G0156, G0157, G0299, Q5001).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH specializes in recovery and their outcome scores demonstrate their level of success. You say that the enrollee meets the CMS LTACH admission criteria, and his ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable discharge. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that LTACH care is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a
participating provider on October 9, 2020.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that the doctor gets paid
enough with Medicare. You say that you cannot afford this copayment. The Plan denied your request. The Plan
says the correct copayment has been applied.
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 $325
copayment for outpatient surgery/in-network.
You have been asked to pay a $325 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls
within the outpatient surgery/in-network 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 an outpatient surgery provided by a participating provider on October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays and intraoral x-rays you received on November 10, 2020.
You asked the Plan to pay for the x-rays. The Plan denied your request. The Plan says the benefit limit has been reached.
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 services are subject to a benefit limitation. The Plan covers one set of bitewing x-rays and one set of intraoral x-rays per calendar year. The records show that you received covered bitewing x-rays and intraoral x-rays on June 9, 2020. The requested x-rays exceed the benefit limit, and therefore are not covered. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays and intraoral x-rays you received on November 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hearing exam provided by a participating
provider on October 14, 2020.
You asked the Plan to waive the copayment for a hearing exam. You say that you were never told that you
would be charged for the additional hearing exam. The Plan denied your request. The Plan says the correct
copayment has been applied.
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 hearing services - Medicare-covered/in-network.
You have been asked to pay a $45 copayment for a hearing exam. Since a hearing exam was provided, the
correct copayment has been applied. A hearing exam falls within the hearing services - Medicare-covered/innetwork
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 hearing exam provided
by a participating provider on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental extraction.

You asked the Plan to pay for the extraction. The Plan denied your request. The Plan says this is 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 services are not among those covered under this benefit. The Plan covers only those dental services for which the codes are listed in the Evidence of Coverage. Dental code D7140 is not listed, and therefore is not covered. Therefore, we decided that the Plan does not have to pay for the dental extraction.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle foot orthosis (CPT code L1971) and foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each (CPT Code L3170) provided to the enrollee on September 16, 2020.
You asked the Plan to pay for the orthotics. You say that the services were necessary. The Plan denied your request. The Plan says the plan was unable to discover any evidence of an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the orthotics have not been met. The plan was unable to discover any evidence of an established relationship between the enrollee and the ordering physician as required per CMS guidelines In addition, documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code. Therefore, we decided that the Plan does not have to pay for ankle foot orthosis (CPT code L1971) and foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each (CPT Code L3170) provided to the enrollee on September 16, 2020.