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

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on September 25, 2019 by an OON provider.You asked the Plan to pay for the subsequent nursing facility care services. You say that this provider is the only wound specialist and works for the nursing home. You also say that this provider saw the enrollee under the impression that there was an authorization on file.The Plan denied your request. The Plan says this provider is a non-network provider who does not work with the enrollee's health plan. The Plan also says that the enrollee was referred by his non-participating nursing facility.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 has network providers available who can provide 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 subsequent nursing facility care services provided on September 25, 2019 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.You asked the Plan to pre-approve incontinence supplies. The Plan denied your request. The Plan says incontinence garments are not covered by Medicare.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the five removals of residual tooth roots and three extractions provided on July 17, 2019.
You asked the Plan to pay for the five removals of residual tooth roots and three extractions. You say that in order to use your dentures more of your teeth had to be extracted. The Plan denied your request. The Plan says this benefit had been exhausted for the 2019 plan year.
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, simple or surgical extractions are limited up to 2 per calendar year. The record shows that you received an extraction of tooth #29 on March 27, 2019 and an extraction of tooth #18 on August 28, 2019, and your simple or surgical extractions benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the five removals of residual tooth roots and three extractions provided on July 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for bone marrow harvesting for transplantation (bone marrow aspirate).
You asked the Plan to pay for bone marrow aspirate. You say that you feel you have been underpaid. The Plan denied your request. The Plan says the denial of payment for this service is correct, because there is no medical evidence that the use of this service improves outcomes and further studies are needed to validate findings.
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 pay for bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental in cases of spinal fusion. More research is needed to support this service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pay for bone marrow harvesting for transplantation (bone marrow aspirate).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Modafinil for the enrollee.
You asked the Plan to pre-approve Modafinil. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Modafinil for the enrollee.
Benefits for Modafinil 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the patient will benefit from physical therapy and rehab, needs assistance with active daily living and needs help with balance. The Plan denied your request. The Plan says that the enrollee's therapy needs can be met on an intermittent basis utilizing part B benefits at a lower level of care such as an long term care facility on dementia unit/memory care unit.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 3 heavy duty power wheelchair and accessories.
You asked the Plan to provide a Group 3 heavy duty power wheelchair (K0858) and accessories. You say that the enrollee is unable to use the prostheses and it is medically necessary to use a power wheelchair for all mobility activities. The Plan denied your request. The Plan says the enrollee does not have a neurological condition, muscle disease, or congenital skeletal deformity.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to provide a Group 3 heavy duty power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and binocular microscopy services provided on July 30, 2019 by an out of network (OON) provider.You asked the Plan to pay for the office visit and binocular microscopy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 onlyin 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 has network providers available who can provide 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 and binocular microscopy services provided on July 30, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on September 24, 2019.You asked the Plan to waive the copayment forlab tests. You say that you were told at this appointment that there would be no charges.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.The rules say a plan must disclose to its enrollees inclear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $35 copayment for in-network lab tests. You have been asked to pay $20.12, which is less than the $35 copayment for lab tests. Lab tests fall 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 copayment forlaboratory testing provided on September 24, 2019.Your complaint regarding not being told about the cost-share for these tests is considered to be a grievance. We do not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional transportation. You say that you need transportation to dialysis. The Plan denied your request. The Plan says once you have used all the trips allowed, no additional trips may be authorized.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Once you have used 24 trips, you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on September 26, 2019.You asked the Plan to pay forthe problem focused limited oral evaluation and intraoral periapical x-rays. You say that you lose your balance and have been falling frequently. You also say that it is very hard for you to keep up with all of the bills you receive.The Plan denied your request. The Plan says you had exceeded the limit set in the subscriber agreement prior to these services being rendered.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 Plan offers a $500 annual dental benefit maximum. The contract says that after your annual deductible benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual deductible benefit on April 3, 2019 and your annual deductible benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Ostomy supplies coded as A4409, A4406, A4371, A4394, A4465, A4385 and A4432 provided January 31, 2019.
You asked the Plan to pay for the Ostomy supplies. You say that per Medicare guidelines a signed deliver ticket is not required and request reconsideration for payment. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The documentation submitted did not include a signed delivery sheet of when the enrollee received the supplies billed. The delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket submitted. Therefore, we decided that the Plan does not have to pay for Ostomy supplies coded as A4409, A4406, A4371, A4394, A4465, A4385 and A4432 provided January 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the initial periapical x-ray (D0220) provided on September 6, 2019.
You asked the Plan to pay for the dental services. You say that one exam and one bitewing per year are covered. You also say that the assistant checked and told you that it was covered. The Plan denied your request. The Plan says the dental services you received are not listed as covered services.
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the initial periapical x-ray (D0220) provided on September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on April 25, 2019.
You asked the Plan to pay for drug tests. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the records do not include definitive laboratory results for 15 to 21 drug classes to support the billing of code G0482.
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 G0482 is drug test(s), definitive, qualitative or quantitative, all sources, including specimen validity testing, per day; 15 to 21 drug classes, including metabolite(s) if performed. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for drug tests. Our reviewer says that the documentation does not support payment for code G0482. Our physician reviewer found only 8 classes of drug testing were ordered, therefore the billing of code G0482 is not supported by the record. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on April 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 22, 2019 by an out of network (OON) provider.You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 has network providers available who can provide 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 provided on August 22, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and the 2D oral or facial photographic image (D0350) provided on September 30, 2019 by the out of network provider.You asked the Plan to pay forthe dental services. You say that the provider status has not changed, only the address.The Plan denied your request. The Plan says the provider in this case was not a network provider on the date of service. The Plan also says that services provided out of network are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, dental services that are provided by an out of network dentist are not covered. The record shows that the dentist in this case was not participating with the Plan until October 31, 2019, after the date of service in thisappeal.Therefore, we decided that the Plan does not have to pay forthe comprehensive periodontal evaluation (D0180) and the 2D oral or facial photographic image (D0350) provided on September 30, 2019 by the out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from July 2, 2019 to September 30, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services that the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from March 24, 2019 to July 1, 2019. The Plan has covered 100 days of SNF care.Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit periodwhen the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from July 2, 2019 to September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe maxillofacial prosthesis procedure provided on June 4, 2019.You asked the Plan to pay forthe maxillofacial prosthesis procedure. You say that your doctor recommended you get a snoring device to relieve mild sleep apnea. You also say that this service was a medical condition and not a dental condition.The Plan denied your request. The Plan says this dental service is not covered by your medical plan.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe maxillofacial prosthesis procedure provided on June 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0481 provided on April 9, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 G0481 is drug test(s), definitive, utilizing (1) drug
identification methods able to identify individual drugs and distinguish between structural isomers (but not
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type,
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g.,
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drugspecific
calibration and matrix-matched quality control material (e.g., to control for instrument variations and
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14
drug class(es), including metabolite(s) if performed.
We find that CPT code G0481 is not supported in the medical record. Specifically, the documentation
submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering
physician) stating exactly what tests are to be performed. Based on this information, we decided that Medicare
rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to
pay for the drug testing coded G0481 provided on April 9, 2019.