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

We decided that the Plan does not have to pre-approve Diazepam 5 mg tablet.
You asked the Plan to pre-approve Diazepam. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under your medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Diazepam 5 mg tablet.
Benefits for Diazepam may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast reconstruction (19366).

You asked the Plan to pay for the breast reconstruction. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 19366 is breast reconstruction with other technique.

We asked our coder 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 breast reconstruction. Our reviewer says that CPT code 196366 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that a Breast reconstruction with other technique was performed, therefore this service cannot be verified.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the breast reconstruction have not been met. Therefore, we decided that the Plan does not have to pay for the breast reconstruction (19366).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307 and G0482) provided on April 10, 2020.
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim submitted indicates that the specimen was collected in a laboratory setting; however, the medical record submitted indicates the specimen was obtain in a rehabilitation facility setting.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Specifically, the claim was submitted with a laboratory place of service code, but the record indicates that the face-to-face service was rendered in a rehabilitation facility setting. Therefore, we decided that the Plan does not have to pay for the drug testing (80307 and G0482) provided on April 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a prescription for Methadone provided from July 11, 2020, through
August 27, 2020.
You asked the Plan to pay for the prescription for Methadone. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 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 a prescription for Methadone provided from July 11, 2020, through August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on August 26, 2020.
You asked the Plan to pay for the durable medical equipment. 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.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services (97810, 97811) provided October 1, 2020 and October 21, 2020.
You asked the Plan to pay for the acupuncture services. You say that benefits were checked and you were informed that the enrollee did have acupuncture coverage. The Plan denied your request. The Plan says this provider is not supervised by any physician, physician assistant, or nurse practitioner or clinical nurse specialist.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, this provider is not supervised by any physician, physician assistant, or nurse practitioner or clinical nurse specialist Therefore, we decided that the Plan does not have to pay for the acupuncture services (97810, 97811) provided October 1, 2020 and October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on November 18, 2020.
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 outpatient hospital services provided on November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walker rigid adjustable or fixed height (E0130) provided May 1, 2020.

You asked the Plan to waive the coinsurance for the walker. You say that you should not be charged the coinsurance. The Plan denied your request. The Plan says the coinsurance 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare covered DME.

You have been asked to pay $11.26 ($56.32 total allowed cost x 20% coinsurance) for the walker. Walkers fall within the Durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the walker rigid adjustable or fixed height (E0130) provided May 1, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve epidural steroid injection (62323).

You asked the Plan to pre-approve the injection. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says that the requested injection is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain with lumbar radiculopathy. She has had 2 prior Epidural Steroid injections. The injections have provided greater than 50% pain relief in the past and have NOT been over-utilized. The request 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 injection have been met. Therefore, we decided that the Plan has to pre-approve epidural steroid injection (62323). 

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 reimburse you for the hearing aids purchased on October 1, 2020 from an out of network provider.
You asked the Plan to reimburse you for the hearing aids from an out of network provider. You say that the digital hearing aids replace old ones and you would like to get partial reimbursement. The Plan denied your request. The Plan says you did not have 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 reimburse you 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 at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to reimburse you for these items. Therefore, we decided that the Plan does not have to reimburse you for the hearing aids purchased on October 1, 2020 from an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on August 21, 2019 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not 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 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 lab work provided on August 21, 2019 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 non-covered chiropractic services (99203).

You asked the Plan to pay for the non-covered chiropractic 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.

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 (99203) is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered chiropractic services (99203).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0650) provided on September 21, 2020.

You asked the Plan to pay for a back brace. You say that this is supported in the records. The Plan denied your request. The Plan says the records do not show that the telehealth visit in which this item was prescribed did not have a qualifying originating site.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. 

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a back brace (L0650) provided on September 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a radiologic examination, knee (73562LT),
and a radiologic examination, pelvis (72170) provided on August 7, 2020.
You asked the Plan to waive the copayment for the radiologic examinations of knee and pelvis. You say that
you brought images to the appointment and do not think it was necessary for the doctor to do additional films.
The Plan denied your request. The Plan says the correct copayment was applied.
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 outpatient diagnostic tests.
You have been asked to pay a $40 copayment for a radiologic examination of knee and pelvis. The services at
issue fall within the outpatient diagnostic 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
copayment for a radiologic examination, knee (73562LT), and a radiologic examination, pelvis (72170)
provided on August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0140), scaling (D4341) and preventive service (D1999) provided on September 29, 2020, through October 1, 2020.
You asked the Plan to pay for the oral evaluation, scaling and preventive service. You say that you would like reconsideration because the provider quote you a lower amount. The Plan denied your request. The Plan says the total liability amount was applied correctly.
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 preventive service is not among those covered under this benefit. Additionally, your cost share has been applied correctly. You have been asked to pay the amount greater than the Maximum Allowable Charge paid by the Plan. Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0140), scaling (D4341) and preventive service (D1999) provided on September 29, 2020, through October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for sectioning of a fixed partial denture (D9120) provided June 29, 2020.
You asked the Plan to pay for the dental service. You say that the enrollee was told by a representative told her that this procedure should be covered. The Plan denied your request. The Plan says this service is not covered under the plan 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. The health plan contract says that any services not listed are not covered. 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 sectioning of a fixed partial denture (D9120) provided June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intraoral x-rays and scaling and root planing (D4346,
D0210).

You asked the Plan to pre-approve the intraoral x-rays and scaling and root planing. You say that the services
were medically necessary. The Plan denied your request. The Plan says these services are not covered 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 pre-approve
intraoral x-rays and scaling and root planing (D4346, D0210).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transport services.
You asked the Plan to waive the copayment for the emergency ambulance transport services. You say that the copayment is too expensive. The Plan denied your request. The Plan says you pay $350 for Medicare-covered ambulance services per trip.
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 $350 copayment for ambulance services. The enrollee has been asked to pay a $350 copayment for the emergency ambulance transport services. These services fall 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 the emergency ambulance transport services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound care services (11042) provided
from October 19, 2020, to October 27, 2020.
You asked the Plan to waive the copayments for the wound care services. You say that you were not an
outpatient and you were only told you would have a copayment for the specialist visits. The Plan denied your
request. The Plan says there is a $275 copayment for each session of outpatient hospital services.
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 $275
copayment for outpatient hospital and observation services.
You have been asked to pay a $275 copayment for each session of wound care services. The specific procedure
you received is called "debridement" and involves removal of skin and tissue around the wound. This service is
classified as a surgical procedure and was provided at an outpatient hospital facility. Anyone not checked into
the hospital as an inpatient is considered an outpatient. These wound care services fall within the outpatient
hospital and observation services 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
wound care services (11042) provided from October 19, 2020, to October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. You say that you provided these services in good faith. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services were not urgent or emergent.

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 physician services provided by an out of network (OON) provider.