Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment to 1 or more regions
other than spine and the x-ray services provided from December 5, 2019 to December 19, 2019.
You asked the Plan to pay for the chiropractic manipulative treatment to 1 or more regions other than spine and
the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your
request. The Plan says the services received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the chiropractic manipulative treatment to 1 or more regions other than spine
and the x-ray services provided from December 5, 2019 to December 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 2, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the emergency room wouldn't let you be transported another way. The Plan denied your request. The Plan says the copayment 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 $250 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls 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 the ambulance transport provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the retrobulbar injection rendered on December 3, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 67500 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 67500 and 00140. Code 67500 is a column II code with a modifier indicator of 1 when billed with column I code 00140. Code 67500 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the retrobulbar injection rendered on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 11, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.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 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 forthe medical services provided to the enrollee by an out-of-network provider on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on June 2, 2019 to August 28, 2019 by an out of network (OON) provider.You asked the Plan to pay for psychotherapy services. You say that this was a continuation of care.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services were not ordered by an in-network providers.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 psychotherapy services provided on June 2, 2019 to August 28, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the
enrollee on August 9, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the documentation submitted did not include lab results or lab report with method of testing.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
In this case, the CPT Code Manual definition of HCPCS code G0482 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 drug-specific 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; 15-21 drug class(es), 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 the services. Our reviewer says that the
services at issue in this case were not coded correctly. Our physician reviewer found the submitted medical
records included an order for drug testing but the completed results of testing performed were not included.
The records do not support the coding of HCPCS G0482.
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 pay for drug testing services (HCPCS G0482) provided to the enrollee on August 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction services (90215) provided November 26, 2019.
You asked the Plan to pay for the vision services. You say that this is a standard test that you have been getting for years from your eye doctor/clinic. These tests were done last year and was processed as a medical claim and you had no out of pocket expenses. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
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. This service is not listed as a covered benefit.
We looked at the file and the Plan's rules. The plan only covers eye exam and eyeglasses after cataract surgery. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for refraction services (90215) provided November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from November 8, 2019 to November 25, 2019.You asked the Plan to waive the copayment for a SNF stay. You say that you were not informed that a previous SNF stay would count toward this SNF day.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 $0 copayment for days 1-20 and a $160 copayment for days 21-62 for SNF care. You had a SNF stay from November 8, 2019 to November 25, 2019. The record shows that you had a previous SNF stay from August 30, 2019 to September 18, 2019 for a total of 19 days. Therefore, you are not being charged a copayment for day 20 (November 8, 2019). You are responsible to pay a $160 copayment for days 21-36 (November 9, 2019 to November 24, 2019). $160 (copayment) x 16 (SNF days) = $2,560.00.You have been asked to pay the total copayment amount of $2,560.00 for a SNF stay. A SNF stay falls within the SNF care 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 SNF stay provided from November 8, 2019 to November 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit/Epogen.
You asked the Plan to pre-approve Procrit/Epogen J0885. You say that you want the Plan to allow you to receive the treatment your doctor has prescribed. The Plan denied your request. The Plan says you have not first tried and had a contraindication or intolerance to Retacrit.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Procrit/Epogen J0885. Our reviewer says that the drug is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Retacrit before they will approve the requested drug. On May 6, 2020 it is documented that the enrollee is on treatment Retacrit. The documentation does not support that Retacrit (Epoetin alfa-epbx) has failed, or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit/Epogen J0885 have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit/Epogen.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has unilateral primary osteoarthritis of the left knee. She has not tried and failed the Plan's required drugs of Orthovisc or Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, the Euflexxa is not reasonable or medically necessary.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond April 26, 2020.
You asked the Plan to pre-approve the continued SNF care. You say that it is felt that SNF care is required. The Plan denied your request. The Plan says the enrollee's needs are custodial. She is not in need of daily skilled care.
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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 78-year-old woman with a past medical history of diabetes, hypertension, COPD, pancreatic cancer, left upper lung mass, chronic pain, dementia, and MRSA. The enrollee presented to the hospital on 4/16/2020 because she was unable to care for herself at home. She had recently lost her husband. The physical examination was unremarkable. The enrollee was diagnosed with failure to thrive with recent loss of a caregiver. She was refusing oxygen and was refusing to have her O2 sat checked. The enrollee was intermittently agitated and combative. She was refusing all care at times. There are no daily skilled nursing or therapy services required. As a practical matter, the enrollee does not required services on an inpatient basis, in a skilled nursing facility setting.
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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond April 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you live alone and are unable to get into the shower by yourself. You say that you are having an amputation surgery and cannot put pressure on your foot for six to eight weeks. If you do so, you say that your stitches will come off. You stated that the shower bench will allow you to get into the shower from your wheelchair by yourself. You say it will be impossible to do so with only one foot because your balance is not good. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME purchased by the enrollee on September 4, 2019
from a non-Medicare provider.
You asked the Plan to pay for the DME. You say that you were under the impression this would be covered by
Medicare. The Plan denied your request. The Plan says the enrollee purchased DME from a non-Medicare
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 service obtained by the member was rendered by a provider who is not under contract with the health plan
and are not certified for Medicare. Per the member's 2019 EOC, the member can get care from out-of-network
providers; however, the provider must be eligible to participate in Medicare. The provider is not certified with
Medicare. Therefore, we decided that the Plan does not have to pay for the DME purchased by the enrollee on
September 4, 2019 from a non-Medicare provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for portable oxygen contents, gaseous, 1 month's supply = 1 unit (CPT Code E0443) provided to the enrollee on November 1, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. This provision is effective January 1, 2006. For beneficiaries receiving oxygen equipment on December 31, 2005, the 36-month rental period begins on January 1, 2006. Section 5101(b) of the DRA of 2005 establishes a 36 month (3 year) limit, or "cap" on monthly payments for stationary and portable oxygen equipment. This cap applies to monthly payments made for oxygen equipment on or after January 1, 2006. The cap applies to all claims for the following HCPCS codes: E0431 -Portable gaseous oxygen system and E1390 -Oxygen concentrator, single delivery port.
There is no further payment for oxygen equipment during the 5-year reasonable useful lifetime (RUL) of the equipment after 36 rental payments have been made. If use of portable equipment (E0431, E0433, E0434, E1392, K0738) begins after the use of stationary equipment begins, payment for the portable equipment can continue after payment for the stationary equipment ends until 36 rental payments have been made for the portable equipment. If the beneficiary was using portable gaseous or liquid equipment during the 36th rental month of stationary equipment (gaseous, liquid, or concentrator), payment for portable contents (E0443, E0444 or E0447) begins when the rental period for the stationary equipment ends. If the beneficiary began using portable gaseous or liquid equipment after starting on stationary equipment, payment for the portable equipment would continue until the end of the 36-month rental period for that equipment even though payment was also being made for the portable contents. The review of this appeal confirms that November 01, 2019 was the 20th month of billing for the rental of equipment code E1390 and 33rd moth of billing for the rental of equipment code E0431 and as a result the benefit limit has not been met. On the first day after the month for which the 36th monthly payment amount is made, the supplier must transfer title for the stationary and/or portable oxygen equipment to the beneficiary. On that same day that title for the equipment is transferred to the patient, monthly payments can begin to be made for oxygen contents used with patient owned gaseous and liquid oxygen equipment. We find that Medicare rule for payment for oxygen content code E0443 has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for portable oxygen contents, gaseous, 1 month's supply = 1 unit (CPT Code E0443) provided to the enrollee on November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fall protection option, for the enrollee.
You asked the Plan to pre-approve a fall protection option. You say that the service is medically necessary. The
Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. The Plan covers the
device along with three different offerings for service, which allow your mother to call for
emergency help by pressing a button. The fall detection option you requested that automatically alerts when a
fall is detected is part of a fourth offering, which is not covered as part of the plan benefits. We understand you
and your mother's primary care provider requested this service as you believe it would be beneficial for your
mother's safety; unfortunately, we are not able to pay for services that are not part of the plan's covered
benefits. The fall protection option is not a covered benefit. Therefore, we decided that the Plan does not have
to pre-approve a fall protection option, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accessory, u-1 sealed lead acid
battery, each (e.g., gel cell, absorbed glassmat) (E2365 X 2), wheelchair accessory, adjustable height,
detachable armrest, complete assembly, each (E0973 X 2) and power wheelchair, group 2 standard, captains
chair, patient weight capacity up to and including 300 pounds (K0823 X 13), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically
necessary. The Plan denied your request. The Plan says the documentation provided does not indicate why a
power operated vehicle such as a motorized scooter, is not sufficient to meet the enrollee's needs.
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 DME. Our physician reviewer
found the records do indicate a walker and/or cane cannot safely be used. But, records do not indicate why a
standard scooter is insufficient to meet this enrollee's needs. Therefore, this request is not medically 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 DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve power wheelchair accessory, u-1 sealed lead acid battery, each (e.g., gel cell, absorbed
glassmat) (E2365 X 2), wheelchair accessory, adjustable height, detachable armrest, complete assembly, each
(E0973 X 2) and power wheelchair, group 2 standard, captains chair, patient weight capacity up to and
including 300 pounds (K0823 X 13), for the enrollee.