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

We decided that the Plan does not have to pay for the outpatient telehealth office visit (99213) provided on
February 10, 2021, by an OON provider.

You asked the Plan to pay for the telehealth visit. You say that you understand that services were rendered by
an out of network provider, but you expect some payment for the services. The Plan denied your request. The
Plan says out of network telehealth services are not covered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 the outpatient telehealth office visit (99213)
provided on February 10, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the claims defined by codes Q0499 and Q0506 provided on
May 20, 2021, by an OON provider.

You asked the Plan to pay for the services at issue. You say that the claim should be reimbursed. The Plan
denied your request. The Plan says there was no prior authorization obtained for the service.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 the claims defined by codes Q0499 and Q0506
provided on May 20, 2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transport
(A0998) provided on May 9, 2021.
You asked the Plan to pay for the ambulance treatment without transport. You say that you felt better after
treatment was provided at your residence, and these services were medically necessary. The Plan denied your
request. The Plan says the ambulance benefit is a transportation benefit. Without transport, there is no payable
service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on May 9, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without
transport (A0998) provided on May 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 1, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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. We find that the laboratory services are not supported in the medical record. Specifically, the the enrollee had molecular pathology testing. When a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. Review of the file does not support that only one single code was billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the fitting, custom preparation, and supply of off-the-shelf depth-inlay shoe (A5500) provided on March 13, 2021.
You asked the Plan to waive the deductible for the diabetic shoes. You say that you do not like the way the podiatrists' office measures for shoes and did not know the provider you chose was out-of-network. The Plan denied your request. The Plan says the cost-share was applied correctly, according to out-of-network benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information. Your contract with the Plan says that there is $500 deductible which applies to Diabetes Self-Management Training, Diabetic Services and Supplies. The item or service you asked the Plan to reimburse falls within the benefit category Diabetes Self-Management Training, Diabetic Services and Supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 deductible which applies to Diabetes Self-Management Training, Diabetic Services and Supplies.
This cost sharing is a contractual obligation that had not been met at the time the diabetic shoes were received on March 13, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the fitting, custom preparation, and supply of off-the-shelf depth-inlay shoe (A5500) provided on March 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on April 30, 2021.

You asked the Plan to waive the copayment for laboratory tests. You say that you should not be charged. The Plan denied your request. The Plan says that 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 $10 copayment for laboratory tests.

You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests 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 laboratory tests provided on April 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vitamin D testing provided on April 28, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the code is not
a Medicare benefit for the diagnosis listed.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Vitamin D
testing provided on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CALR and MPL genetic testing.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the enrollee was found to have elevated hemoglobin of 19/1 n September 3, 2021 and an enlarged spleen and liver. A bone marrow exam demonstrated slightly hypercellular bone marrow with trilineage hematopoiesis, with slight increase in megakaryocytes. The documentation supports that the enrollee's hemoglobin level returned to the normal range, as did his red blood cell count and hematocrit. The documentation does not support that the requested CALR and MPL genetic testing is medically reasonable and necessary for 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve CALR and MPL genetic testing.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on December 3, 2020.

You asked the Plan to pay for the ambulance transport. You say that the hospice coordinator stated the patient was not on hospice at the time of transport. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

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 for the ambulance transport provided on December 3, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for WATS 3D biopsy testing provided on March 29, 2021.
You asked the Plan to pay for laboratory testing. You say that the enrollee's treating physician ordered this
testing after making a professional determination of medical necessity. The Plan denied your request. The Plan
says that the denial of payment for this testing is correct, because the medical literature and clinical practice
guidelines does not support the clinical utility of this testing.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
This testing was ordered by an in-network physician. The file does not show that the plan provided notice that
laboratory testing would not be covered. Under Medicare rules, this means laboratory testing is considered
approved by the plan. Therefore, we decided that the Plan has to pay for WATS 3D biopsy testing provided on
March 29, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on September 24, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 out of network physician services provided to the enrollee on September 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
April 21, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you had to have an 
additional mammogram done due to a faulty film and feel that you should not be held responsible for 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 a $60 
copayment for X-rays. 
 
The medical records show that you received a diagnostic mammogram on April 21, 2021. Therefore, you are 
responsible to pay the $60 copayment.   
 
You have been asked to pay a $60 copayment for a diagnostic mammogram. A diagnostic mammogram falls 
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 a diagnostic mammogram provided on April 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 9, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the health 
Plan requires utilization of network providers when possible and available and requires authorization for 
certain services. No necessity for an out-of-network provider, such as an urgent or emergency situation has 
been documented. 
 
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 
service 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 physician's services provided on June 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 21, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 14 to June 23, 2021.

You asked the Plan to pay for psychotherapy services. You say that you thought that Medicare understood the importance of mental health care and sought to cover counseling. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 14 to June 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for rituximab (J9312) provided on May 20, 2021.
You asked the Plan to waive the coinsurance for rituximab (J9312). You say that because the chemotherapy you received in 2018 was paid in full, you think it should be paid in full now. 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 20% coinsurance for chemotherapy drugs in a specialist's office. You have been asked to pay $891.40 ($4,457 Allowed Amount x 20% coinsurance =$891.40) for one Rituximab Injection and $479.59 (3,387.32 Allowed Amount x 20% coinsurance=$677.46) for another Rituximab injection. You are being asked to pay less than 20% coinsurance (the required cost-share) in total for these services. These injections fall within the Medicare Part B 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 rituximab (J9312) provided on May 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for a walker purchased on February 18, 2021.

You asked the Plan to pay for a walker purchased from a retail provider. You say that you were told a walker could be covered. The Plan denied your request. The Plan says durable medical equipment must be obtained from a Medicare eligible provider.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided by a provider who is not a Medicare eligible provider. This walker was purchased from a retail or commercial provider who is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for a walker purchased on February 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 enrollee is not shown to require fifteen hours per week of rehabilitative services 
and regular physician evaluation. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the cardiovascular stress test (93015) and
myocardial perfusion imaging, tomographic (SPECT) (78452) provided on June 23, 2021.
You asked the Plan to waive the deductible for the testing services. You say that these services were approved
for coverage and you did not realize that you would be responsible for this cost. You say you would not have
had these necessary tests if you knew how much you would have to pay. The Plan denied your request. The
Plan says these claims were processed correctly, and the deductible was applied in accordance with your
contract.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible which applies to basic and advanced imaging
services.
The items or services you asked the Plan to waive the deductible for fall within the benefit category basic and
advanced imaging services. The Plan has followed Medicare rules by clearly disclosing in the contract that
there is a $750 deductible which applies to basic and advanced imaging services. This cost sharing is a
contractual obligation that had not been met at the time testing services was received on June 23, 2021.
Therefore, we decided that the Plan does not have to waive the deductible for the cardiovascular stress test
(93015) and myocardial perfusion imaging, tomographic (SPECT) (78452) provided on June 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visits (99600) provided from June 20, 2021, to June 23, 2021.
You asked the Plan to pay for the home visits. You say that the enrollee's doctor and the hospital recommended this treating company and said that the enrollee's insurance would pay for 50% of the services. You also say that the enrollee inquired about being reimbursed prior to receiving the services and was told they would be reimbursed. The Plan denied your request. The Plan says these services were rendered by a non-participating provider who is not certified with Medicare.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home visits have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the home visits (99600) provided from June 20, 2021, to June 23, 2021.