Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (K0800).
You asked the Plan to pre-approve a power operated vehicle. You say that you would like this powered vehicle for use in the store if the store's scooter were being used by someone else. The Plan denied your request. The Plan says this item is not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (K0800).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two removals of an impacted tooth (D7240 x2).
You asked the Plan to pre-approve the removals of an impacted tooth. You say that you need these services approved because you are in a lot of pain. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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 pre-approve two removals of an impacted tooth (D7240 x2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a multiplex respiratory viral panel (87631) provided on
February 19, 2021.
You asked the Plan to pay for a multiplex respiratory viral panel. You say that this should be covered as an innetwork
service. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that panels of 3-5 pathogens are covered under
limited circumstances. Specifically, the test must be ordered either in a healthcare setting that is equipped to
care for and routinely does care for critically ill patients, or it must be ordered by an infectious disease
specialist, unless an infectious disease specialist is not available.
We looked at the file and Medicare rules. The records do not show that this test was ordered either in a
healthcare setting that is equipped to care for and routinely does care for critically ill patients or by an
infectious disease specialist, Based on this information, we decided that Medicare rules for coverage of a
multiplex respiratory viral panel have not been met. Therefore, we decided that the Plan does not have to pay
for a multiplex respiratory viral panel (87631) provided on February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes (A5500) to be provided by an out of network provider.
You asked the Plan to pre-approve diabetic shoes. You say that you want to have this durable medical equipment that was prescribed by your doctor. The Plan denied your request. The Plan says rules for out of network care have not been met.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes (A5500) to be provided by an out of network provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0481) provided on December 22, 2020, by an out of network (OON) provider.
You asked the Plan to pay for drug testing. You say that prior authorization is not required for this test. You also say that you have attached supporting documentation and would like the claim processed. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 drug testing (80307, G0481) provided on December 22, 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 services provided by an out-of-network provider on February 10, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81185, 81238, 81286, 81403, 81404, 81405, 81406, 81410, 81411, 81439, 81479) provided on September 24, 2020.
You asked the Plan to pay for a hereditary cardiovascular screening. You say that these services are supported in the records. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening (81185, 81238, 81286, 81403, 81404, 81405, 81406, 81410, 81411, 81439, 81479) provided on September 24, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for specialist services and coinsurance for an injection for date of service March 3, 2021. We decided that the Plan does not have to waive the copayment and coinsurance for specialist services and an injection provided on January 20, 2021.
You asked the Plan to waive the copayment for specialist services and coinsurance for an injection. You say that you do not agree with these charges. The Plan says that the correct charges have been applied.
We decided that the Plan has to waive the copayment for specialist services and coinsurance for an injection for date of service March 3, 2021. The Plan has failed to provide information to verify the amount owed for March 3, 2021. Therefore, we decided that the Plan has to waive the copayment and coinsurance for specialist services and an injection.
We also decided that the Plan does not have to waive the copayment for specialist services and coinsurance for an injection provided on January 20, 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 20% coinsurance of the allowed amount for an injection and a $45 copayment for specialist services. The total allowed amount is $4.30. The amount you are being asked to pay for the injection is $0.86 ($4.30 x 20% = $0.86). The total amount you are being asked to pay is $45.86 ($45 + $0.86 = $45.86). Therefore, we decided that the Plan does not have to waive the copayment and coinsurance for specialist services and an injection.
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 pre-approve two posts and cores in addition to crowns (D2952 x2).
You asked the Plan to pre-approve the posts and cores. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 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 pre-approve two posts and cores in addition to crowns (D2952 x2).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on February 16, 2021.
You asked the Plan to waive the coinsurance for the denosumab injection. You say that the shot cost more than a specialist would charge. You say that you are appealing the bill. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Part B covered chemotherapy drugs and 20% for other Part B covered drugs.
You have been asked to pay $241.32, which is 20% of the allowed amount for the denosumab injection. The allowed amount is $1,206.60 (20% x $1,206.60 = $241.32). The denosumab injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on February 16, 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 January 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the porcelain/ceramic crown (D2740) and core buildup (D2950) provided January 13, 2021.
You asked the Plan to pay for the porcelain/ceramic crown and core buildup. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that this is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has failed to provide a relevant Evidence of Coverage to detail what supplemental services are covered under the Plan. Therefore, we decided that the Plan has to pay for the porcelain/ceramic crown (D2740) and core buildup (D2950) provided January 13, 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 pre-approve facet joint blocks.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says narcotics appear to have been the only treatment for this pain.

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the physical exam of the lumbar spine is normal.

There is no imaging of the lumbar spine, and there is no documentation of conservative therapy. The request is not medically reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature for a powered mobility device.
You asked the Plan to pre-approve a power seat elevation feature. You say that the requested item 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 item is not a benefit of Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered. Based on this information, we decided that Medicare rules for coverage of a power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature for a powered mobility device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81227, 81291, 81225, 81226) provided on
October 15, 2020.
You asked the Plan to pay for genetic testing. You say that this testing was medically necessary. The Plan
denied your request. The Plan says this testing was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. We find that CPT codes 81227, 81291, 81225, and 81226 are not supported in the medical record. Specifically, the record shows that the testing at issue was performed as a panel, meaning it should be reported as a single code. 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 genetic testing (81227, 81291, 81225, 81226) provided on October 15, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Intron (J9214).
You asked the Plan to pre-approve Intron. You say that Intron is medically necessary. The Plan denied your
request. The Plan says that coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Intron. Our reviewer says that Intron is
medically necessary. Our physician reviewer found for those who recur despite BCG therapy, the combination
of BCG with interferon alfa-2b Intron) does appear to be an effective alternative treatment. It is safe and
effective. Use is supported by the medical literature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Intron have been met. Therefore, we decided that the Plan has to pre-approve
Intron (J9214).
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 services provided by an out-of-network provider on
February 19, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.
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 February
19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on
October 20, 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. Medicare does not cover
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary
cardiovascular screening testing provided on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on January 30, 2020.
You asked the Plan to pay for this service. You say that you rely on the facility to obtain prior authorization. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network services provided to the enrollee on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 17,
2021.
You asked the Plan to pay for this service. You say that this claim should be paid the Plan. The Plan denied
your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan 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 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 physician services provided to the enrollee on February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglass frames (V2020).
You asked the Plan to pre-approve frames. You say that your eyeglasses broke and would like coverage for a new pair. The Plan denied your request. The Plan says you have already used your $300 eyewear benefit and are not eligible for further coverage for routine eyewear.
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 once every two years. We looked at the file and the Plan's rules. The Plan previously provided coverage for eyeglasses in February 2021. Based on this information, we determined that you are not yet eligible for an additional eyewear allowance. Therefore, we decided that the Plan does not have to pre-approve eyeglass frames (V2020).