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

We decided that the Plan does not have to pay for the laboratory services provided on May 13, 2021 by an out-of-network (OON) 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 an out-of-network 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 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 May 13, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided on February 3, 2021.

You asked the Plan to pay for a pneumatic compression device (E0676). You say that the Plan should pay this claim. The Plan denied your request. The Plan says this device is not covered by Medicare to prevent deep vein thrombosis.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 

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, this item is not a covered benefit of Medicare or the Plan.

This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (83516, 88230, 88240, 88241, 83520, 83516, 86332, 86353, 86356, 86359, 88112, 88184, 88185, 88346, 88350) provided January 19, 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 these tests are not covered for screening purposes.
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. Therefore, we decided that the Plan does not have to pay for the lab services (83516, 88230, 88240, 88241, 83520, 83516, 86332, 86353, 86356, 86359, 88112, 88184, 88185, 88346, 88350) provided January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 4, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network 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 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 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 services provided by an out-of-network provider on August 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (71045) provided on May 5, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.

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 71045 has a bundled relationship with code 71046 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 the services (71045) provided on May 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care 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 LTACH services are not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from and improve with LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient domiciliary, rest home, or custodial
Care visit (99336) provided on February 26, 2021, by an OON provider.

You asked the Plan to pay for the domiciliary, rest home or custodial care visit. You say that it was medically
necessary for the enrollee to receive the treatment and you did not know that the facility failed to get pre-authorization
for this enrollee, so you treated them anyway. The Plan denied your request. The Plan says
enrollee's must receive their medical services from an in-network provider with the exception being urgent or
emergent services. Non-emergent services with non-contracted providers require prior authorization before
services being rendered.

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 the established patient domiciliary, rest home, or
custodial Care visit (99336) provided on February 26, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the coinsurance for continuous glucose monitor (CGM) sensors you purchased on December 21, 2020.
You asked the Plan to waive the coinsurance for the CGM sensors. You say that you do not understand why you keep getting billed for these supplies. The Plan denied your request. The Plan says that you were charged this coinsurance correctly because the allowed amount per month for these supplies is over $500.
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 enrollees do not pay cost sharing for diabetes supplies, including supplies to monitor your blood glucose. The sensors you purchased are supplies used with a CGM to monitor your blood glucose, so they fall into the diabetic supply benefit category. According to your contract, items in this category do not have cost sharing associated with them. The Plan contends that the durable medical equipment cost sharing applies. While the Evidence of Coverage states that diabetic supplies are covered under the durable medical equipment benefit, that information is contrary to the language in the Diabetic Services and Supplies section of the Evidence of Coverage. Diabetic supplies cannot fall into both categories, so we find that the Plan's contract is not clear. A reasonable person would not be able to tell, based on the language of the Plan's document, under which benefit section diabetic supplies would be covered. Due to this lack of clarity, we can only conclude that the benefit section that is more beneficial to you would apply. The diabetic supply category, as noted above, clearly includes supplies used to monitor blood glucose. That includes CGM sensors. Based on the language of the contract, a reasonable person would conclude that there would be no cost sharing associated with these items. Therefore, we decided that the Plan has to waive the coinsurance for continuous glucose monitor (CGM) sensors you purchased on December 21, 2020.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 29, 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 the services are not covered.
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, a cardiovascular risk assessment panel, 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 rendered on December 29, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing services provided to the enrollee on April 6, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that there is no written order for this testing.

The Plan must follow Medicare rules. The rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. 

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 pay for the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the ordering provider wrote the order for genetic testing for this enrollee. The enrollee has a diagnosis of malignant neoplasm - upper lobe, left bronchus, or lung. The testing is medically reasonable and necessary. 

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 services have been met. Therefore, we decided that the Plan has to pay for genetic testing services provided to the enrollee 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation (A0429) provided on March 20, 2021.
You asked the Plan to waive the copayment for emergency ambulance transportation. You say that the enrollee should not be responsible for the charges. The Plan denied your request. The Plan says the copayment was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $125 copayment for ambulance services. The enrollee has been asked to pay a $125 copayment for emergency ambulance transportation. The service at issue falls within the ambulance services 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 copayment for emergency ambulance transportation (A0429) provided on March 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with a gastroenterologist on April 22, 2021.
You asked the Plan to waive the copayment for the telehealth visit. You say that this was a consult prior to a colonoscopy. You said that it should be considered part of the colonoscopy. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for telehealth visits with a specialist. You have been asked to pay a $40 copayment for the telehealth visits. Medicare rules state that in order for preoperative visits to be paid as part of the global surgical package (in other words, not separately payable from the procedure itself), the preoperative visit must occur on the day before or the day of the surgery. In this case, this consultation occurred on April 22, 2021, and you did not have your colonoscopy until May 15, 2021. Because this consult occurred far outside of this global surgical period, it is a separately payable service for which a copayment can apply. 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 telehealth visit you had with a gastroenterologist on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and intraoral x-ray provided on May 19, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and intraoral x-ray. You say that they had the option to check your insurance before they did the work. You say that you were not advised they were not in-network until after they were finished, and you should not be responsible for the charges. The Plan denied your request. The Plan says out-of-network dental services are not covered.

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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and intraoral x-ray provided on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight testing (81479) provided on October 6, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for GeneSight testing. You say that this was medically necessary. 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 GeneSight testing (81479) provided on October 6, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology (88305) rendered by the out-of-network (OON) provider on April 22, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the surgical pathology (88305) rendered by the out-of-network (OON) provider on April 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the enrollee needs the requested therapy to regain strength. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested care is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there is no documentation that the enrollee requires skilled nursing services. The enrollee does require skilled therapy services; however, daily skilled services are not required. As a practical matter, based on the medical records provided, the enrollee does not require the services on an inpatient basis only in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on April 23, 2021.
You asked the Plan to pay for the scaling. You say that your dental plan states that there is a $0 copay for exams, cleanings, and x-rays. You also say that the Plan denied payment for the teeth cleaning service. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns (D2740), core buildup (D2950), and endodontic therapy (D3320) provided on May 17, 2021.
You asked the Plan to pay for the crowns (D2740), core buildup (D2950), and endodontic therapy (D3320). You say that the dental plan didn't cover the services you received. The Plan denied your request. The Plan says the services are not covered 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.
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 crowns (D2740), core buildup (D2950), and endodontic therapy (D3320) provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on April 26, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that the provider did not render the service they promised. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify 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. 

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 problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on April 26, 2021.