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

We decided that the Plan does not have to pay for the rest home visit provided on March 6, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the rest home visit. You say that the hospital staff failed to obtain authorization and the doctor should not be penalized. You say the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 rest home visit provided on March 6, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and radiologic examination provided on
March 29, 2021.
You asked the Plan to pay for the office visit and radiologic examination provided by a chiropractor. You say
that you paid your copayment, so you do not owe anything. The Plan denied your request. The Plan says an
office visit and radiologic examination when provided by a chiropractor are not covered services.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the office visit and radiologic examination provided on March 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the magnetic resonance imaging (MRI) of the arm you had on February 18, 2021, and the MRI of the pelvis you had on February 20, 2021 at an outpatient hospital facility.
You asked the Plan to waive the copayments for the MRIs. You say that you were not informed of these costs prior to receiving the services and you cannot afford this. The Plan denied your request. The Plan says you were charged these copayments 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 $250 copayment for advanced imaging services in an outpatient hospital.
You have been asked to pay a $250 copayment for the MRIs. The MRIs fall within the advanced imaging services in an outpatient hospital 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 copayments for the magnetic resonance imaging (MRI) of the arm you had on February 18, 2021, and the MRI of the pelvis you had on February 20, 2021 at an outpatient hospital facility.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on September 18, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. This testing was ordered by an out-of-network podiatrist and the lab requisition form does not indicate a specific diagnostic purpose for this testing. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing provided on September 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) and armrests (E0973).
You asked the Plan to pre-approve an expandable controller and armrests. You say that these items are necessary due to your paralysis. The Plan denied your request. The Plan says these items are not needed.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is medically necessary for the functions described in the LCD. Armrests are included in the allowance for the corresponding power tilt and/or recline seating systems when provided at the same time. 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 an expandable controller and armrests. Our reviewer says that the requirements for coverage of the requested items have not been met. Our physician reviewer found based on the records provided, your strength in the right upper extremity and ability to feed yourself independently support that you can control any power options through their own individual switches rather than needing an expandable controller. The armrest is not separately covered with the approved power seating system. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller and armrests have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) and armrests (E0973).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a portable oxygen concentrator for the enrollee.
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says that Medicare does not pay for oxygen related to air travel.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mm Hg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 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 concentrator. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, the enrollee has chronic hypoxic respiratory failure and is on supplemental oxygen. The record indicates that the enrollee performed a six-minute walk in January 2021. The pre-test oxygen saturation was 98% and the post test saturation was 88% on room air. The enrollee is using supplemental oxygen at home that is covered. The elements of the coverage rule are satisfied. 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 concentrator have been met. Therefore, we decided that the Plan has to pre-approve a portable oxygen concentrator for the enrollee.
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 a comprehensive oral evaluation (D0150) provided on February 15, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that you were not aware of the frequency limitation. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 3 years.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on January 6, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis testing (81455) provided on January 19, 2021.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting documents. The Plan denied your request. The Plan says this testing is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that genetic testing code 81455 will be automatically denied for date of service January 19, 2021. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis testing (81455) provided on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided on March 9, 2021.
You asked the Plan to pay for a comprehensive periodontal evaluation. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 a comprehensive periodontal evaluation (D0180) provided on March 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report
rendered on February 27, 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 93010 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 93010 (EKG interpretation and report) and 92928
(percutaneous transcatheter placement of intracoronary stents). Code 93010 is a column II code with a modifier
indicator of 1 when billed with column I code 92928. Code 93010 was not billed with an appropriate modifier
to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the
electrocardiogram (EKG) interpretation and report rendered on February 27, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) care provided from November 1, 2020, through November 9, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copay per day, for days 1-20 and a $178 copay per day, for days 21-100, for Medicare-covered skilled nursing facility stays rendered by an in-network provider.
You have been asked to pay $1,309.88 ($178 copay x 9 days) for the inpatient skilled nursing facility care
rendered by an in-network provider. This amount is less than the applicable copayment for these services as
you have now met the annual out of pocket cost allowable for this year. 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 skilled nursing facility (SNF) care provided from November 1, 2020, through
November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on February 23, 2021.
You asked the Plan to pay an additional amount for a periodic oral evaluation, and a teeth cleaning. You say that the services at issue should be covered. The Plan denied your request. The Plan says the claims for these services were processed correctly with the applicable out-of-network allowable amount paid.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, and a teeth cleaning have not been met.
Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the set of 4 bitewing x-rays (D0274) provided on October 8, 2020.

You asked the Plan to pay for the bitewing x-rays. You say that you were following your provider's recommendations. You also say that you do not have the funds to pay for this service. The Plan denied your request. The Plan says 1 set of bitewing x-rays are 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 set of 4 bitewing x-rays that you received on March 11, 2020. Therefore, we decided that the Plan does not have to pay for the set of 4 bitewing x-rays (D0274) provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) provided on August 11, 2020.

You asked the Plan to pay for an intraoral complete series of radiographic images. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

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 an intraoral complete series of radiographic images (D0210) provided on August 11, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.

You asked the Plan to pre-approve Durolane. You say that this request is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Durolane. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. In this case, the enrollee has osteoarthritis of the knee. The record indicates that the enrollee has tried and failed Monovisc. The enrollee has not tried and failed Orthovisc. The prescriber has not indicated that Orthovisc would not be appropriate for the enrollee. The elements of the coverage rule are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames (V2020), progressive lens, per lens (V2781), vision item or service, miscellaneous (V2799), and polarization, any lens material, per lens (V2762) provided January 6, 2021.

You asked the Plan to pay for the frames, progressive lenses, miscellaneous vision item or service and lens polarization. You say that you would like the eyewear to be covered. The Plan denied your request. The Plan says the eyewear was provided out-of-network and therefore were not covered under your vision benefits at the time of service.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by a vision network provider. 

We looked at the file and the Plan's rules. In this case the routine eyewear was provided by an out-of-network provider. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of the frames, progressive lenses, miscellaneous vision item or service and lens polarization have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020), progressive lens, per lens (V2781), vision item or service, miscellaneous (V2799), and polarization, any lens material, per lens (V2762) provided January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve referral to a tertiary-level ophthalmologist.

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 tertiary level of care is 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 tertiary level of care is not medically necessary. Our physician reviewer found you have diabetes without
complications and other medical conditions. You require a vision examination. The records do not support that
the tertiary level of care is reasonable or medically necessary. Your care can be provided by a network nontertiary
ophthalmologist.

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 referral to a tertiary-level ophthalmologist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for genetic testing (81479) provided on December 15, 2020.

You asked the Plan to waive the coinsurance for genetic testing. You say that the Plan should pay additional payments to the provider. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.

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 outpatient diagnostic tests and therapeutic services and supplies including molecular and predisposed genetic testing.

You have been asked to pay a 20% coinsurance for genetic testing. The allowed amount of the claim is $3,500, resulting in a coinsurance obligation of $700. The EOC confirms 20% is the required coinsurance for this service. Genetic testing 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 coinsurance for genetic testing (81479) provided on December 15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient behavioral health services provided from January 8, 2021, to February 26, 2021.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says these services were rendered by a provider who is not eligible to bill Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided by a physician or practitioner who is not Medicare eligible. The services at issue in this appeal were rendered by a provider who is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for outpatient behavioral health services provided from January 8, 2021, to February 26, 2021.