Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician or allowed practitioner re-certification for Medicare-covered home health services (G0179) provided on April 12, 2021 by an OON provider.

You asked the Plan to pay for the physician or allowed practitioner re-certification. You say that this treatment was medically necessary so as not to compromise the enrollee's health and well-being. The Plan denied your request. The Plan says prior authorization was not obtained.

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 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 physician or allowed practitioner re-certification for Medicare-covered home health services (G0179) provided on April 12, 2021 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to establish safety and effectiveness. 

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Lynch Syndrome genetic testing rendered on May 6, 2021.
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 testing is not covered.
The Plan must follow Medicare rules. Medicare rules say that Lynch Syndrome testing is covered when specific criteria are met. We looked at the file and Medicare rules. The file shows that you do not have a personal history of cancer for which this testing is covered. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Lynch Syndrome genetic testing rendered on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on February 12, 2021.
You asked the Plan to waive the copayment for the lab services You say that you were under the impression that there was no copayment for lab services. You say that these labs were done at your doctor's office. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that there is no copayment for lab services if you get them at a physician's office or an independent lab location. The Plan says that because you received these lab services at a hospital facility, the copayment applies.
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 $25 copayment for lab services received at any location other than a doctor's office or an independent lab location.
You have been asked to pay a $25 copayment for the lab services. Records show that the facility where you received these services and that billed for these services is considered an outpatient hospital facility. 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 lab services you received at an outpatient hospital facility, on February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply (K0553) provided February 9, 2021.
You asked the Plan to pay for CGM supply allowance. You say that you would not have dispensed the product without receiving the verification establishing coverage under the enrollee's plan and the approved authorization that was required. The Plan denied your request. The Plan says that the documentation does not have an appropriate proof of delivery.
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. In this case, the Plan denied that the documentation does not have appropriate proof of delivery. We find that the records was provided with a valid proof of delivery for the supplies provided in this case. The Plan did not substantiate their reason that the proof of deliver was not appropriate. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of supply allowance have been met.
Therefore, we decided that the Plan has to pay for the supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply (K0553) provided February 9, 2021.
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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the dental services provided on March 16, 2021.
You asked the Plan to pay for core buildup on tooth #8 (D2950), porcelain fused to high noble metal (D6240), and retainer crown (D6750). You say that you believed the contract provider had called the Plan and verified your benefits. The Plan denied your request. The Plan says that codes D6240 and D6750 are not covered and you exceeded the limit on code D2950.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not forward the Dental Schedule of Benefits as requested therefore, benefits cannot be verified. Therefore, we decided that the Plan has to pay for the dental services provided on March 16, 2021.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from June 1, 2021, to June 4, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that you were in the hospital in March for the same issue and feel you should not have to pay this copayment because the services were necessary and should have been resolved during your previous stay. The Plan denied your request. The Plan says the services were approved for coverage, but you are responsible for your copayment. This claim was 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 $195 copayment for each of the first six days of an inpatient hospital admission. These services are covered by the Plan, but you are responsible for your share of the cost. You have been asked to pay a $585 copayment for three days of inpatient care ($195 x 3 = $585). 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 inpatient hospital admission and services provided from June 1, 2021, to June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 26, 2021.
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 procedure code 85610 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 85610 is prothrombin time. We find that CPT code 85610 is not supported in the medical record. Specifically, there are no laboratory results to support that prothrombin time testing was performed. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker purchased on the internet April 20, 2021 by the enrollee.
You asked the Plan to pay for equipment purchased on the internet. You say that the enrollee bought the walker online because the in-network provider did not have the equipment needed. The Plan denied your request. The Plan says online equipment purchases are not covered by Medicare. The Plan also states the in-network provider could have ordered the walker needed.
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.
Internet retailers are not network providers with the Plan. The Plan had network providers available who could have ordered this equipment for the enrollee. The Plan did not pre-approve this walker. We found no exception that would require the Plan to pay for this walker. Therefore, we decided that the Plan does not have to pay for a walker purchased on the internet on April 20, 2021 by the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76705) provided May 3, 2021.

You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is not separately payable.

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 76705 has a bundled relationship with code 76700 and cannot be paid as billed. 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 ultrasound (76705) provided May 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. Our physician reviewer found that your condition does not meet Medicare criteria for these services. 

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Vertiflex Superion device placement surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.

You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric hospital bed is medically necessary for the enrollee. The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99350) provided on April 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for a home visit. You say that this should be covered due to the pandemic. The Plan denied your request. The Plan says this was 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 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 a home visit (99350) provided on April 22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on December 1, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this claim was not filed timely.
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 this service was not filed until April 22, 2021. 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 physician services provided to the enrollee on December 1, 2019.
Appeal type: Hospice
Decision: Favorable

We decided that the Plan has to pay for an office visit for nurse practitioner services provided on April 6, 2021.
You asked the Plan to pay for office visit for nurse practitioner services. You say that the member was not hospice eligible when the services were rendered on April 6, 2021. The Plan denied your request. The Plan says that the member is enrolled in a hospice.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide us with proof of Hospice enrollment. Therefore, we decided that the Plan has to pay for an office visit for nurse practitioner services provided by on April 6, 2021.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from January 28, 2021 to February 11, 2021.
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 occurrence code 50 and date are not submitted.
The Plan must follow Medicare rules. The rules say to use occurrence code 50 in place of the service date to report the default discharge date for informational only claims. We looked at the file and Medicare rules. The file shows that the services were not billed with the required occurrence code 50. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from January 28, 2021 to February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 27, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network provider.
You asked the Plan to pre-approve dental services. You say that the Plan has sent you to 4 different dentists over 2 years and you still have not received the requested items/services. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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. The Plan covers dental services when received from a participating dental network provider. We looked at the file, Medicare rules, and the Plan contract. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Specifically, dental services received from an out-of-network provider cannot be authorized. Therefore, we decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 11, 2021 by a non-participating 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 a non-participating 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 referring provider 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 the laboratory services provided on February 11, 2021 by a non-participating provider.