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

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on
December 18, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you met the MOOP
amount for 2019 and disagree with the charges. 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 the
MOOP amount for 2019 is $6,200. Your contract with the Plan also clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You received Medicare Part B drugs on December 19, 2019. The record shows that you had only paid
$5,222.25 toward the $6,700 MOOP amount prior to receiving the services. Therefore, you are responsible to
pay the remaining MOOP balance of $972.75, which is less than the 20% coinsurance amount.
You have been asked to pay $972.75 for Medicare Part B drugs. Medicare Part B drugs fall 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 for
Medicare Part B drugs provided on December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lenses (V2500) purchased March 16, 2019.
You asked the Plan to pay for the contact lenses. You say that you used a doctor in the vision network to get the prescription. You purchased the contact lenses outside the network at a cheaper cost. The Plan denied your request. The Plan says enrollee's must receive their services from a provider in the vision network.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when rendered by a vision network provider. We looked at the file and the Plan's rules. enrollee's must receive their services from a provider in the vision network. Based on this information, we decided that the Plan's rules for coverage of the contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for the contact lenses (V2500) purchased March 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99497 provided on August 16, 2019.You asked the Plan to pay for CPT code 99497. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99497 is Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.We find that CPT code 99497 is not supported in the medical record. Specifically, CPT code 99497 is a time based code. In order to bill CPT code 99497, the documentation must note that the first 30 minutes were face-to-face with the patient, family member(s), and/or surrogate for advance care planning. The progress note for August 16, 2019 does not note how much of the time spent was for advanced care planning. As such, the provided documentation does not support the billing of CPT code 99497. Based on this information, we decided that Medicare rules for coverage of CPT code 99497 have not been met.Therefore, we decided that the Plan does not have to pay for CPT code 99497 provided on August 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99285) provided on June 1, 2019. You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service was included in CPT code 99291 which was billed by a provider with the same specialty in the same group. 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, we have confirmed that code the emergency department visit has a bundled relationship with code 99291 and cannot be paid as billed. The record does not indicate that this service was separately identifiable service. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an emergency department visit (99285) provided on June 1, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe echocardiography provided on November 27, 2019.You asked the Plan to pay forthe echocardiography. You say that the enrollee presented with shortness of breath that had worsened on this date of service. You also say that the enrollee was discharged from the hospital and also had an echocardiography on this date of service.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe echocardiography provided on November 27, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab infusions.
You asked the Plan to pre-approve Rituximab infusions. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Rituximab infusions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental consultation (D9310) provided February 20, 2020.You asked the Plan to pay for the dental consultation.. You say that you are appealing denial of your claim for a consultation with an oral surgeon. This consult was for possible tongue cancer not for any dental problem.The Plan denied your request. The Plan says this service is not covered under the plan benefits.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. services not listed under the Description of Benefits is not covered by the plan.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 consultation (D9310) provided February 20, 2020.
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 February 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 February 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory work provided on January 29, 2020. You asked the Plan to waive the copayment for the laboratory work. You say that your benefits plan allows for one pap-test at $0 a year. You say you are seeking reimbursement for the $10 copayment. 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 $10 copayment for each covered in-network lab service. You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were charged separately for the laboratory work and you were not charged by your provider for the cervical cancer screening. 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 laboratory work provided on January 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's condition must be of a level of complexity that requires an intensive and coordinated interdisciplinary approach including physician visits at least three times weekly.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level does not require or indicate that this therapy must be in an IRF with an intensive level program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 17, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency 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 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 17, 2019.
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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH), having been admitted with Covid-19 following recent cardiac surgery. The enrollee is not currently intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe laboratory services, the blepharoplasty, and repair of blepharoptosis services received on January 9, 2020.You asked the Plan to waive the coinsurance forthe laboratoryservices, the blepharoplasty,and repair of blepharoptosis services. You say that you disagree with the amount owed.The Plan denied your request. The Plan says the claims have been processed correctly per your plan 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). Your contract with the Plan clearly says that you must pay 20% coinsurance for laboratory services. You have been asked to pay 20% coinsurance for the laboratory services, the blepharoplasty and repair of blepharoptosis services. The blepharoplasty and repair of blepharoptosis services fall within the outpatient surgery 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 coinsurance forthe laboratoryservices,the blepharoplasty,and repair of blepharoptosis services received on January 9, 2020.
Appeal type: Outpatient Therapies
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 December 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates the enrollee's insulin treatment regimen does not require frequent adjustment by the patient based on blood glucose monitor or CGM testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met.Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myocardial Perfusion Imaging (78452). You asked the Plan to pre-approve Myocardial Perfusion Imaging. You say that the test is medically necessary. The Plan denied your request. The Plan says rules for coverage are not met. The Plan follows Medicare rules. Medicare rules say that Myocardial Perfusion Imaging is covered when 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 Myocardial Perfusion Imaging. Our reviewer says that the Myocardial Perfusion Imaging is not medically necessary. Our physician reviewer found in this circumstance additional stress testing with nuclear imaging is not medically necessary since the records show a stress that has recently been performed and is negative for ischemia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Myocardial Perfusion Imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve Myocardial Perfusion Imaging (78452).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the inpatient hospital care provided May 21, 2019 to May 29, 2019.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the copayment has been applied correctly to the inpatient hospital care provided.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 $370 copayment per day for days 1 through 5 for covered hospital care. You havebeen asked to pay a $1,850 copayment ($370 x 5 days) for the inpatient hospital care providedto the enrollee. This means that youhavebeen asked to pay the correct amount based on the enrollee's contract with the Plan. This cost sharing is a contractualobligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copaymentfor the inpatient hospital care provided May 21, 2019 to May 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) segmental pneumatic appliance (E0667).You asked the Plan to pre-approve a pneumatic compression device. You say that you respectfully as for reconsideration for a Flexitouch pneumatic compression device which is prescribed to treat his lymphedema.The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a basic pneumatic compression device of either E0650 or E0651. The plan has however approved the enrollee for E0651 as the enrollee meets the Medicare criteria of this device.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 pre-approve a pneumatic compression device (E0652) segmental pneumatic appliance (E0667)