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

 We decided that the Plan does not have to pay for lab services (88120) provided April 5, 2021.  You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim was not billed with a valid diagnosis.  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, Genetic testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Bladder tumor markers are not expected to be performed until other diagnostic studies fail to identify the etiology of the hematuria. Urine cytology is not considered a bladder tumor marker. Therefore, we decided that the Plan does not have to pay for lab services (88120) provided April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (88305, 88312) provided on October 21, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-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 services at issue in this appeal. 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 lab services (88305, 88312) provided on October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing (81479) provided April 16, 2021.  You asked the Plan to pay for the genetic testing. You say that the genetic test was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that SelectMDx is covered in males with previous negative prostate biopsy who are being considered for repeat biopsy.  We looked at the file and Medicare rules. The record does not show a previous negative prostate biopsy. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided April 16, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for self-administered drugs (A9270) provided in the emergency room from October 28, 2021, to October 29, 2021.  You asked the Plan to pay for the self-administered drugs. You say that this service should be covered. The Plan denied your request. The Plan says the charge at issue is for self-administered drugs dispensed in an outpatient setting. These drugs are not eligible for coverage under the Part B medical benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs (A9270) provided in the emergency room from October 28, 2021, to October 29, 2021.   Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for hand finger orthosis, without joints (L3924) provided on October 12, 2021.  You asked the Plan to waive the coinsurance for hand finger orthosis, without joints. You say that you were not aware there would be 20% coinsurance and would not have done through insurance if you had known, as they are available at a lower cost online. The Plan denied your request. The Plan says you were 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 20% coinsurance for covered items for durable medical equipment and related supplies.    You have been asked to pay a $20.02 in coinsurance, which is 20% of the allowed amount for each hand finger orthosis, without joints ($80.06 allowed amount x 20% coinsurance = $20.02), for a total of $40.04 ($20.02 coinsurance x 2 orthosis devices = $40.04). A hand finger orthosis, without joints falls within durable medical equipment and related 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 coinsurance for hand finger orthosis, without joints (L3924) provided on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction provided on October 18, 2021.  You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says the eye refraction was for a medical vision check (central retinal vein occlusion, left eye, with macular edema). Eye refractions are only covered by your Plan if performed by a participating vision provider and performed as a routine screening per your 2021 Evidence of Coverage.  Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.   We looked at the file, the Medicare rules and the Plan's rules. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for outpatient surgery services you received on October 19, 2021.  You asked the Plan to waive the deductible for the outpatient surgery services. You say that the doctor did not tell you up front that you were going to have surgery.  You said that you feel as though they are charging too much. The Plan denied your request. The Plan says you were assessed this deductible correctly.  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 outpatient surgery.   Records show that on the date of service, you had an incision procedure of the humerus (procedure code 24000).  This procedure is considered an outpatient surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the outpatient surgery services were received on October 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible for outpatient surgery services you received on October 19, 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 requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 We decided that the Plan has to fix the deductible amount for the physical therapy services provided from September 8, 2021, to September 16, 2021.  You asked the Plan to fix the deductible amount for the physical therapy services. You say that  The Plan denied your request. The Plan says that there is a $0 copayment once the deductible is met for each therapy visit and the proper deductible amount was applied.  We decided that the Plan has to fix the deductible amount for the physical therapy sessions provided from September 8, 2021, to September 16, 2021.  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 $750 deductible for is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Once you have paid your deductible, we will begin to pay our share of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the calendar year.  The amount paid towards the deductible prior to September 8, 2021, was $339.69. On September 8, 2021, there was a deductible amount of $177.58 bringing to total deductible paid amount to $517.27 ($339.69 starting deductible + $177.58 deductible charged). On September 9, 2021, there was a deductible amount of $123.95 charged bringing the total deductible amount to $641.22 ($517.27 prior deductible paid + $123.95 deductible charged). On September 13, 2021, there was a deductible amount of $157.32 charged bringing the total deductible amount to $798.54 ($641.22 prior deductible paid + $157.32 charged deductible) which put the enrollee over the $750 deductible. On September 16, 2021, there was a deductible amount of $75.41 charged bringing the total deductible amount to $873.95 ($798.54 prior deductible + $75.41 charged deductible). The total amount over the deductible paid was $123.95 ($873.95 total deductible charged - $750 max amount of the deductible.  Therefore, we decided that the Plan has to fix the deductible to $750 for the overcharge of $123.95 for the physical therapy services provided from September 8, 2021, to September 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 9, 2021.  You asked the Plan to pay for the dental service. You say that the x-ray you received in April 2021 was taken in order to examine a single problematic tooth. You say that it was not used for diagnostic purposes. You also say that this should be covered. The Plan denied your request. The Plan says 1 set of bitewing x-rays is covered per plan year. The Plan also says that the frequency limit has been exceeded.  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 and bitewing x-rays are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a bitewing x-ray that you received on April 19, 2019. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on July 6, 2021.  You asked the Plan to pay for the ambulance service. You say that your cat bit you. You say that you could not control the bleeding on your own. You also say that you did not go to the hospital since the paramedic was able to stop the bleeding. The Plan denied your request. The Plan says there was no transport provided on the date of service. The Plan also says that since no transport was provided, 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 July 6, 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, no transport, (A0998) provided on July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the DecisionDx-SCC test (81599) provided on September 23, 2021.  You asked the Plan to pay for code 81599. 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 as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that code 81599 is not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (81599) provided on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2377, E2313, E2311).  You asked the Plan to pre-approve the expandable controller. You say that the expandable controller is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that expandable controllers are 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 the expandable controller. Our reviewer says that the expandable controller is not medically necessary. Our physician reviewer found the provided records document that the enrollee is independent with feeding, grooming, and toileting thus indicating she has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches.  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 expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2377, E2313, E2311).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra eye drops.  You asked the Plan to pre-approve Xiidra. You say that they enrollee has been on this therapy and is stable with shown improvements. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.       The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra eye drops.   Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller, harness, and electronic connection device for a power wheelchair.  You asked the Plan to pre-approve expandable controller, harness, and electronic connection device. You say that you need this due to your condition. The Plan denied your request. The Plan says the denial of authorization for these components is correct, because your upper limb function is adequate to control the wheelchair's power options through their own switches.  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 expandable controller, harness, and electronic connection device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not need to control your wheelchair's power options through a joystick. Your upper extremity strength and function support that you can use your wheelchair's power options with their own switches.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of expandable controller, harness, and electronic connection device have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, and electronic connection device for a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 17, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from February 17, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric care from February 17, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of February 17, 2022, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond February 17, 2022, as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from February 17, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 17, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on November 27, 2019, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that the provider billed wrong for the services provided. The Plan denied your request. The Plan says there was no proper referral from an authorized physician. Therefore, services were denied.  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 provided on November 27, 2019, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a denosumab injection rendered on August 31, 2021.  You asked the Plan to waive the coinsurance for a denosumab injection. You say that your concern is that the amount of this in the past was $40 or $50, and now all of a sudden, they have added other services of $157, which we never paid in the past. You also ask why you had to pay $184. The Plan denied your request. The Plan says you were 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs.   The enrollee has been asked to pay a $184 in coinsurance, which is 20% of the allowed amount for a denosumab injection ($919.98 allowed amount x 20% coinsurance = $184). A denosumab injection falls within the Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a denosumab injection rendered on August 31, 2021.