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

We decided that the Plan does not have to pre-approve the requested physical therapy services.
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says
you must receive care from in-network providers with the exception of emergency or urgent care, dialysis
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider,
which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the
requested physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upgraded electronics, power seating system, expandable joystick, or mobile device charger.You asked the Plan to pre-approve the upgraded electronics, power seating system, expandable joystick, and mobile device charger.You say that you need the power wheelchair, upgraded electronics and accessories.The Plan denied your request. The Plan says power seat elevation systems and mobile chargers are not primarily medical in nature. The Plan says the power wheelchair comes with a joystick, and the upgraded electronics are not necessary for the power seat feature on the wheelchair.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The seat elevation feature and device charger at issue in this appeal do not serve a purpose that is primarily medical in nature.The expandable controller system is not necessary and the wheelchair comes with a joystick. Therefore, we decided that the Plan does not have to pre-approve upgraded electronics, power seating system, expandable joystick, or mobile device charger.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegeri chair/rollabout chair (E1031).You asked the Plan to pre-approvegeri chair/rollabout chair. You say that if unable to get tilt in space wheelchair this would be the next best device for at home and continued PT and OT therapies.The Plan denied your request. The Plan says the request for geri chair/rollabout chair is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve geri chair/rollabout chair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found per records a DME Consulting evaluation on 3/25/20 stated a Geri chair is not medically necessary. Such a device is only provided to facilities who use the device between enrollee's as a mobile out of bed positioning device. The requested Geri chair does not appear to be furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the enrollee's condition or to improve the function of a malformed body member. The requested Geri chair exceeds the enrollee's medical needs and is not medicallynecessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of geri chair/rollabout chair have not been met.Therefore, we decided that the Plan does not have to pre-approvegeri chair/rollabout chair (E1031).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided from January 31, 2020 to February 11, 2020. 
 
You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says you must use a contracted and/or approved provider or supplier for the services to be covered and follow all rules for the benefit selected. 
 
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 acupuncture services provided from January 31, 2020 to February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 8,
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 Healthcare Common Procedure Coding System (HCPCS) G0481 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be
covered.
The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly tests were to be performed. 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 provided to the enrollee on July 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on February
24, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that the lab work was ordered for
your wellness exam. You say that the Plan has covered this for years. 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 $35
copayment for lab services at an in-network outpatient hospital.
You have been asked to pay a $35 copayment for the laboratory services. The laboratory services fall within
the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic
tests are considered a separate service. 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 laboratory
services provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on January 21, 2020.
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 provider is no longer credentialed or eligible for Medicare/Medicaid billing of services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the denied codes not supported in the medical record. Specifically, the codes are not allowed to be billed, as the provider is no longer credentialed. 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 lab services provided to the enrollee on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy services, the specialist office visits, laboratory services, and the outpatient hospital surgical services provided from February 4, 2019 to October 10, 2019. 
 
You asked the Plan to waive the copayments for the physical therapy services, the specialist office visits, laboratory services, and the outpatient hospital surgical services. You say that you would like the plan to pay these claims. The Plan denied your request. The Plan says the services have been processed correctly per your plan benefits. 
 
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 physical therapy, $250 copayment for outpatient surgery services, $40 copayment for specialist services, and a $5 copayment for laboratory services. 
 
Review of the file shows that you received eight (8) physical therapy services from February 4, 2019 to February 22, 2019. You are being asked to pay a $320 copayment total for these services. You received a specialist office visit on February 12, 2019, August 28, 2019, and September 13, 2019. You are being asked to pay a $120 copayment total for these services. You received outpatient hospital surgical services from June 7, 2019 to June 26, 2019, July 5, 2019 to July 26, 2019, and August 9, 2019. You are being asked to pay a $1750 copayment total for these seven (7) services. You received laboratory services on October 10, 2019. You are being asked to pay a $5 copayment for this service. 
 
You have been asked to pay a $40 copayment for each of the physical therapy services, a $40 copayment for each of the specialist office visits, a $250 copayment for each of the outpatient hospital surgical services, and a $5 copayment for laboratory services. 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 the physical therapy services, the specialist office visits, laboratory services, and the outpatient hospital surgical services provided from February 4, 2019 to October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 3, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe chiropractic care. You say that you would like reconsideration as the member is benefiting greatly from chiropractic care.The Plan denied your request. The Plan says utilization of network providers is required when possible and available.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 forthe medical services provided on January 3, 2020 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 medical services provided on June 11, 2019 to June 26, 2019 by an out of network (OON) provider. 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 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 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 medical services provided on June 11, 2019 to June 26, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from
March 4, 2019 to September 4, 2019.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you normally pay
$5.57 and disagree with the additional charges. 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 20%
coinsurance for DME and related supplies.
You received DME and related supplies from March 4, 2019 to September 4, 2019 for a total of 7 dates of
service. The total allowed amount per each date of service is $265.43 and 20% of that is $53.08. The total
amount you owe is: $58.08 (coinsurance) x 7 (dates of service) = $371.56.
You have been asked to pay the total coinsurance amount of $371.56 for DME and related supplies. DME and
related supplies fall within the 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 DME and related supplies provided from March 4, 2019 to September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 6, 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 received are not a covered benefit when provided by an OON 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 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 December 6, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on January 6, 2020.
You asked the Plan to pay for lab tests. You say that this testing was medically necessary, ordered by the
treating facility, and may not have been available from in-network laboratories. The Plan denied your request.
The Plan says that the denial of payment for these services is correct, because this provider is out-of-network
with the Plan and authorization was not obtained.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a
contract provider are considered approved by the plan unless notice is provided that the services will not be
covered.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not specify whether the ordering provider was in-network or outof-
network with the Plan. The documentation submitted did not include prior notice from the Plan that these
services would not be covered. Without this information, we cannot determine whether the lab order made
constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for these
services is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for
laboratory testing provided on January 6, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low vision clinic services to be provided by an out-of-network provider. You asked the Plan to pre-approve the low vision clinic services. You say that your doctor advised you after your eye surgery that you would need a low vision provider. You went to the provider office and they have the equipment there that can help you read. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. Low vision aids is not covered by the plan. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when services are provided by an in-network provider. Low vision service are not covered under the plan benefits. We looked at the file and the Plan's rules. Enrollees must receive their vision services from an in-network provider. Low vision services are not covered under the plan benefits. Based on this information, we decided that the Plan's rules for coverage of the low vision clinic services have not been met. Therefore, we decided that the Plan does not have to pre-approve low vision clinic services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services (97811, 97810) provided on January
28, 2020.
You asked the Plan to pay for acupuncture services. You say that you were told this was covered. The Plan
denied your request. The Plan says this was not provided by a physician.
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 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. The file shows that these services were provided by an acupuncturist,
not provided by a physician as required by Plan rules. Based on this information, we decided that the rules for
coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pay for acupuncture services (97811,
97810) provided on January 28, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on February 19, 2020. 
 
You asked the Plan to pay for genetic tests. You say that the provider informed the enrollee that the Plan would cover these tests. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because these tests are investigational. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 
 
The enrollee was referred for genetic tests by an in-network provider. The file does not show that the plan provided notice that genetic tests would not be covered. Under Medicare rules, this means genetic tests is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on February 19, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forfluoroscopic guidance for needle placement (77002) provided on December 4, 2019.You asked the Plan to pay forthe fluoroscopic guidance for needle placement. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code 77002 was billed without an appropriate primary code. 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, we have confirmed that code the fluoroscopic guidancefor needle placement is a Type I add-on code. A Type I add-on code has a limited number of identifiable primary procedure codes, and in this case, CPT code 77002 was not billed with an appropriate primary procedure code.  This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forfluoroscopic guidance for needle placement (77002) provided on December 4, 2019.