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

We decided that the Plan does not have to pay for the gene panel testing (CPT code 81206, 81162, 81292, 81295, 81298, 81301) provided to the enrollee on July 7, 2020.
You asked the Plan to pay for the gene panel testing. You say that the test was regarded by the enrollee's doctor as a medically necessary and valuable tool in determining treatment for the enrollee. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the gene panel testing have not been met. Based on the Medicare criteria listed above, the gene panel testing for this enrollee is not medically reasonable or necessary because the enrollee has ovarian cancer, and not the non-small cell lung cancer or metastatic colorectal cancer. Therefore, we decided that the Plan does not have to pay for the gene panel testing (CPT code 81206, 81162, 81292, 81295, 81298, 81301) provided to the enrollee on July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on March 11, 2021 by an OON provider.
You asked the Plan to pay for the resin-based composite. You say that if you cannot see your regular dentist and have the provider or yourself paid, you will be requesting termination from your plan. The Plan denied your request. The Plan says this service is rendered by a non-participating provider.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on March 11, 2021 by an OON provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on November 4, 2020.

You asked the Plan to pay for drug testing. You say that you are appealing with supporting documents to
justify the drug classes billed. The Plan denied your request. The Plan says that the denial of payment for this
testing is correct, because the documentation submitted does not show that 22 or more drug classes were tested
to support the code 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. In this case, the CPT Code Manual definition of
code G0483 is drug testing of 22 or more drug classes.

We find that CPT code G0483 is supported in the medical record. Specifically, the lab results submitted include
test results for more than 22 drug classes. Based on this information, we decided that Medicare rules for
coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for drug testing
provided on November 4, 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 drug testing rendered on March 24, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on March 24, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the second copayment for a CT scan provided by a participating provider on February 3, 2021.
You asked the Plan to waive the second copayment for a CT scan. You say that you should only be charged for one CT scan. The Plan denied your request. The Plan says that the correct copayments have been applied.
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 must pay a $250 copayment for outpatient diagnostic tests/CT scans. The Plan says you must pay a $250 copayment for a CT scan. Based on the Plan contract, however, you are responsible for a $250 copayment per visit for a CT scan. Therefore, we decided that the Plan has to waive the second copayment for a CT scan provided by a participating provider on February 3, 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 waive the cost share forthe dialysis services and lab services provided November 3, 2020, to January 12, 2021.

You asked the Plan to waive the cost share for the dialysis services and lab services. You say that you were told there was no copayment.The Plan denied your request. The Plan says the cost share has processed correctly in this case.

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 Medicare-covered outpatient dialysis. 

You have been asked to pay a 20% coinsurance for the dialysis services and a 5$ copayment for the lab services. The dialysis services fall within the Medicare-covered outpatient dialysis benefit category and the lab services fall within the laboratory tests 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 cost share for the dialysis services and lab services provided November 3, 2020, to January 12, 2021.

Your complaint about potentially receiving misinformation regarding your cost share is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the gastrointestinal services provided on September 30, 2020 by an out of network provider.

You asked the Plan to pay for the gastrointestinal services. You say that the enrollee presented a Medicare card on arrival. The Plan denied your request. The Plan says you did not request 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 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 gastrointestinal services provided on September 30, 2020 by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 1, 2021.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

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 February 1, 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 services provided on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical
radiographic image (D0220), a partial upper denture (D5213), an unspecified adjunctive procedure (D9999),
and a fixed partial denture sectioning (D9120) provided from May 13, 2020, through June 15, 2020.

You asked the Plan to pay for a limited oral evaluation, an intraoral periapical radiographic image, a partial
upper denture, an unspecified adjunctive procedure, and a fixed partial denture sectioning. You say that you
were not aware that the provider had opted out of Medicare. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.

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 limited oral evaluation, an intraoral periapical radiographic image, a partial upper denture, an unspecified adjunctive procedure, and a fixed partial denture sectioning have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), a partial upper denture (D5213), an unspecified adjunctive procedure (D9999), and a fixed partial denture sectioning (D9120) provided from May 13, 2020, through June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous implantation of a neurostimulator electrode array (64555).

You asked the Plan to pre-approve an implantation of a neurostimulator. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an implantation of a neurostimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has other clear pain generators that have not been addressed. The placement of a peripheral nerve stimulator is experimental/investigational at this time.

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 implantation of a neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous implantation of a neurostimulator electrode array (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99201) x-ray cervical spine (72040) manual lymphatic drainage (97140) provided November 3, 2020 to November 13, 2020.
You asked the Plan to pay for the chiropractic services. You say that you believe the communication between the provider and the Plan during your first appointment failed to accurately provide you with the amount that is your responsibility for each visit would be. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99201) x-ray cervical spine (72040) manual lymphatic drainage (97140) provided November 3, 2020 to November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99214) provided to the enrollee on February 25, 2021, by an out-of-network provider.

You asked the Plan to pay for the office visit. You say that the claim should be paid.The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility. The Plan states the provider should have verified the enrollee's eligibility, health benefits and obtained authorization prior to the enrollee's visit before providing services to the enrollee as outlined on the enrollee's identification card.

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 office visit (CPT code 99214) provided to the enrollee on February 25, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 19, 2020.
You asked the Plan to pay for the laboratory services. 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 looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair with seat lift mechanism.

You asked the Plan to pre-approve a recliner chair with seat lift mechanism. You say that this item is medically necessary. The Plan denied your request. The Plan says the coverage criteria have not been met.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. The rules also say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a recliner chair with seat lift mechanism. Our reviewer says that the requested seat lift mechanism is not medically reasonable and necessary. Our physician reviewer found the documentation does not reveal objective evidence of severe arthritis of the hip or knee and/or a neuromuscular disease. There are no objective imaging documents indicating this diagnosis and it is not listed on the medical progress notes.

The medical office visit progress notes do not discuss a seat lift or how it will improve the patient's condition or arrest or retard deterioration in the patient's condition. The medical office visit progress note records do not show that the patient is completely incapable of standing from a chair in the home or an objective neuromuscular exam or gait evaluation indicating the patient can ambulate. The criteria for a seat lift have not been met. Furthermore, the seat lift recliner is statutorily not covered by Medicare.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a recliner chair with seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a recliner chair with seat lift mechanism.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prescription frames and lenses, over the counter medications, transportation services, and other miscellaneous medical items/services purchased from January 9, 2021, to January 31, 2021, under the Flex benefit.

You asked the Plan to pay for miscellaneous medical items/services under the flex benefit. You say that you do not think this claim processed correctly.The Plan denied your request. The Plan says that your plan does not offer a benefit to cover these services. 

The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. Medicare does not offer or mandate a Flex benefit to cover miscellaneous medical items and services. The Plan has chosen not to provide a supplemental benefit for Flex services. 

We looked at the file and Medicare rules. The Plan does not offer an additional benefit to cover Flex items/services.Therefore, we decided that the Plan does not have to pay for prescription frames and lenses, over the counter medications, transportation services, and other miscellaneous medical items/services purchased from January 9, 2021, to January 31, 2021, under the Flex benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device.
You asked the Plan to pre-approve a MyoPro Motion G Orthotic device. You say that this is medically necessary. The Plan denied your request. The Plan says that peer reviewed literature considers the use of robotic therapy for upper and lower extremity stroke rehabilitation investigational in nature.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a MyoPro Motion G Orthotic device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. At this time the requested robotic orthosis is not proven to be more beneficial for treatment of your medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for you, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. Our physician reviewer found that your condition does not meet criteria for a MyoPro Motion G Orthotic device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MyoPro Motion G Orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care visit you had on February 12, 2021.
You asked the Plan to waive the copayment for the primary care visit. You say that you believed you were going to the doctor for your annual wellness visit, which doesn't have a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the medical records from this date of service show that you had a routine office visit for high blood pressure, which is not an annual wellness visit. The Plan also says that you had your annual wellness visit on February 28, 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 $5 copayment for each primary care visit.
You have been asked to pay a $5 copayment for the primary care visit. The medical records from this visit indicate this was not an annual wellness visit. In fact, the records show that you were instructed to return at a later time for an annual wellness visit. 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 primary care visit you had on February 12, 2021.