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

We decided that the Plan does not have to pre-approve a folding walker (E0143, E0156).
You asked the Plan to pre-approve a folding walker. You say that the enrollee is a fall risk. The Plan denied your request. The Plan says the enrollee was previously approved for a walker.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a walker. A walker serves the same purpose as a folding walker. Therefore, we decided that the Plan does not have to pre-approve a folding walker (E0143, E0156).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on April 29, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that this claim is not for an urgent service and you are asking for reconsideration. 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 an office visit (99203) provided on April 29, 2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee from July 4, 2020, to July 7, 2020.
You asked the Plan to pay for this service. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee from July 4, 2020, to July 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (84439, 80061, 82306, 84443, 80053, 36415) rendered by the out-of-network (OON) provider on April 12, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 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 laboratory services (84439, 80061, 82306, 84443, 80053, 36415) rendered by the out-of-network (OON) provider on April 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts.
You asked the Plan to pre-approve foot orthotics (L3000). You say that you need the inserts. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy with a Licensed Professional Counselor.
You asked the Plan to pre-approve psychotherapy, 60 minutes with patient (90837). You say that you have been seeing this counselor for 15 years and established a wonderful relationship with her. The Plan denied your request. The Plan says a Licensed Professional Counselor is not eligible to enroll in Medicare.
The Plan must follow Medicare rules. Medicare rules say that no Medicare payment may be made for items or services provided directly by a physician or practitioner who is not eligible to enroll in Medicare. We looked at the file and Medicare rules. The provider is not qualified to receive payment under Medicare or the benefit plan. Based on this information, we decided that Medicare rules for coverage of psychotherapy, 60 minutes with patient (90837) have not been met. Therefore, we decided that the Plan does not have to pre-approve psychotherapy with a Licensed Professional Counselor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on April 29, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says the services billed by your provider are not related to manual
manipulation of the spine and are not covered by Medicare.
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 chiropractic
services provided on April 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on June 15, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says due to the enrollee's hospice status on the date of service, this claim must be submitted to Original Medicare first. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery you had on March 4, 2021.
You asked the Plan to waive the copayment for the cataract surgery. You say that because you requested to not have anesthesia, you believe you should not have to pay a copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $100 copayment for outpatient surgery. You have been asked to pay a $100 copayment for the cataract surgery. The cataract surgery falls within the outpatient surgery benefit category. This copayment applies for all surgeries, regardless of whether anesthesia is used. 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 cataract surgery you had on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on December 15, 2020.
You asked the Plan to pay for the drug testing. You say that this testing is medically necessary and should be paid. The Plan denied your request. The Plan says the POS code reported is not appropriate.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. There is not sufficient evidence to support that this sample was taken directly by the laboratory, meaning that POS code 81 is not supported. 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 definitive drug testing provided on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) and retainer crown - porcelain fused to high noble metal (D6750) for tooth 3 and fixed partial denture sectioning (D9120).
You asked the Plan to pre-approve core buildup and retainer crown for tooth 3 and fixed partial denture sectioning. You say that you would like the services covered. The Plan denied your request. The Plan says it is not possible to put a crown on a tooth that is missing. 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 Plan covers core buildup and retainer crown for tooth 3 and fixed partial denture sectioning when the services are medically necessary and reasonable. 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 core buildup and retainer crown for tooth 3 and fixed partial denture sectioning. Our reviewer says that that the core buildup and retainer crown for tooth 3 are not medically necessary. Our physician reviewer found the X-rays in the case file show that tooth #3 is missing. Therefore, the documentation support that the core buildup and retainer crown for tooth #3 is medically reasonable and necessary as the tooth is absent. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of core buildup and retainer crown for tooth 3 are not met. Though the Plan offers dental benefits in excess of Medicare coverage, fixed partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) and retainer crown - porcelain fused to high noble metal (D6750) for tooth 3 and fixed partial denture sectioning (D9120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the side guards (K0108.
You asked the Plan to pre-approve the side guards. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the side guards are not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the side guards (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve individualized wrist-worn neuromodulation therapy.
You asked the Plan to pre-approve an external upper limb tremor stimulator of the peripheral nerves of the wrist (K1018). You say that you want to try this device. The Plan denied your request. The Plan says this device is not covered by Medicare, the efficacy is still uncertain, and it was not ordered by a neurologist. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The supplier's website states "Medicare will pay for medical equipment and supplies only if a supplier has a Medicare supplier number. We do not have a Medicare supplier number therefore Medicare will not pay for any medical equipment and supplies we sell or rent to you. You will be personally and fully responsible for payment." This device is not covered by Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of an external upper limb tremor stimulator of the peripheral nerves of the wrist (K1018) have not been met. Therefore, we decided that the Plan does not have to pre-approve individualized wrist-worn neuromodulation therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower denture (D5120) provided on April 19, 2021.
You asked the Plan to pay for the dental services. You say that before any work was done, you verified that all costs would be covered by your insurance. You say that you were given 3 different locations and you chose the one closest to your home. You say that you were not told that the location made a difference as to whether or not you would be covered. You also say that the provider verified the services would be covered as well. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed 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 performed out of network are not among those covered under this benefit. Additionally, the record shows that there were no calls placed to the Plan to discuss in network dental providers prior to the date of service in this case. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower denture (D5120) provided on April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair for use outside of the home.
You asked the Plan to pre-approve power wheelchair. You say that you are stuck in the house and would like to be able to get out of the house. The Plan denied your request. The Plan says this device is not covered by Medicare for use outside of the home.
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 wheelchair for use outside of the home.
Please note that this decision is only regarding your request for a power wheelchair. Please contact the Plan regarding appeals for any other items or services you have requested.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for bladder procedures you had at an outpatient hospital facility from March 1, 2021, to April 19, 2021.
You asked the Plan to waive the copayments for the bladder procedures. You say that these copayments are high for the treatment you received. The Plan denied your request. The Plan says you were charged these copayments correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for surgery services in an outpatient hospital facility. You have been asked to pay a $300 copayment for the bladder procedures. The bladder procedures fall within the surgery services in an outpatient hospital facility 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 bladder procedures you had at an outpatient hospital facility from March 1, 2021, to April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99199, S1015, S8301) provided on December 22, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. 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 services. Our reviewer says that the use of code 99199 is not supported by the records provided. Our reviewer found that the medical records indicate services were performed by an anesthesiologist. Therefore, it is inappropriate for an anesthesia practitioner to bill code 99199 for these services. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 99199 have not been met. Additionally, codes S1015 and S8301 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the services (99199, S1015, S8301) provided on December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air purifier.
You asked the Plan to pre-approve an air purifier.. You say that you need this to breathe air without contamination. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an air purifier.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on April 28, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the correct copayment has been 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 $220 copayment for ambulance services. You have been asked to pay a $220 copayment for ambulance services. The correct copayment has been applied to the services that were provided. Ambulance services fall within the ambulance 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 copayment for ambulance services provided by a participating provider on April 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transport brackets and pelvic belt (K0108).
You asked the Plan to pre-approve the transport brackets and pelvic belt. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this item is solely used for transporting the wheelchair outside the home.
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. Of note, this equipment is specifically for transporting the wheelchair outside of the hope. Therefore, we decided that the Plan does not have to pre-approve the transport brackets and pelvic belt (K0108).