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

We decided that the Plan does not have to pre-approve physician services to be provided by an OON provider.
You asked the Plan to pre-approve physician services. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says the services requested are neither emergent nor urgent to
seek out-of-network care. The Plan says that there are in-network providers available to you that can provide
the services you are requesting.
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 items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
physician services to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for the 2 extractions (D7140) provided on November 12, 2020.
You asked the Plan to waive the out of network cost share for the dental services. You say that you had to have your tooth repaired. You say that no dentist in your plan's network would repair it. You also say that you had to go out of network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network providers may bill you for any amount greater than the MAC payment made by the plan to the provider.
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 and extractions are listed as covered, out of network providers may bill you for any amount greater than the MAC payment made by the plan to the provider. The member liability is a contractual obligation under the plan and cannot be waived. Therefore, we decided that the Plan does not have to waive the out of network cost share for the 2 extractions (D7140) provided on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crowns (D6751) for teeth # 12 and 15, and the pontic (D6241) for teeth # 13 and 14 provided on November 10, 2020.
You asked the Plan to pay for the dental services. You say that prior to receiving these services, the provider received an estimate of how much your insurance would pay for the treatment. You also say that The Plan denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontics are not listed as covered services either. The Plan also says that dental services that are not listed 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retainer crowns (D6751) for teeth # 12 and 15, and the pontic (D6241) for teeth # 13 and 14 provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on June 2, 2020.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 an office visit (99203) provided on June 2, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve Durolane. You say that the requested Durolane is medically necessary. The
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first.
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 Durolane. Our reviewer says that the
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of
Orthovisc and Monovisc first before they will approve the requested drug. In this case, the enrollee has not
tried and failed the required drug(s). There is no documentation provided indicating that the plan's required
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have
to pre-approve Durolane.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is with lumbar spinal stenosis and neurogenic claudication. The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Positron Emission Tomography (PET) scan (78815) provided October 29, 2020.
You asked the Plan to waive the copayment for the PET scan. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct amount was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for PET Scans in the outpatient hospital setting. You have been asked to pay a $200 copayment for the PET scan which was performed in the outpatient hospital setting. 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 Positron Emission Tomography (PET) scan (78815) provided October 29, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan denied your request. The Plan says the enrollee must either have a history of osteoporotic fracture or has tried and failed Zoledronic Acid.
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 Prolia. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires either a history of osteoporotic fracture or a failed trial of Zoledronic Acid before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on December 3, 2019.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 diagnostic radiology services. 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 diagnostic radiology services provided on December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 14, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that this item was medically necessary for the enrollee. The Plan denied your request. The Plan says the patient did not receive a video or telephonic visit by the ordering physician in order to warrant the code billed.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is subject to the criteria listed in the Medicare rules section. 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 lumbar-sacral orthosis. Our reviewer says that the requested items is not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation and a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on October 19, 2020.
You asked the Plan to pay for foot orthotics. You say that you have planters fasciitis. 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 pay for foot orthotics provided on October 19,
2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 29, 2020 to July 2, 2020.

You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, claims are required to be billed on the Original Medicare form, CMS-1450, also known as the UB-04. The docuemtnation does not support that the services were billed on this claim form. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from June 29, 2020 to July 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 7,
2020, to October 8, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the enrollee presented to the emergency room with chest tightness and shortness of
breath. The enrollee was evaluated and the enrollee's physical exam was unremarkable. The enrollee's
electrocardiogram was without acute changes. The documentation does not support that at the time of inpatient
admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including
earlier emergency department and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from October 7, 2020, to October 8,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (G0482) provided July 2, 2020.
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid Place of Service (POS).
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 CPT code G0482 is not supported in the medical record. Specifically, the claim shows Place of Service 81- Laboratory, however the medical records show that the specimen was obtained in an office setting (POS 11). Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (G0482) provided July 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system represented by code
E2300 and a related electronic connection device as code E2311 to be provided with the approved power
wheelchair.
You asked the Plan to pre-approve a power seat elevation system and a related electronic connection device.
You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says
these items are not covered.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered
because it is not primarily medical in nature.
Although these features may be appropriate, neither Medicare nor the Plan can provide coverage for these
items. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system
represented by code E2300 and a related electronic connection device as code E2311 to be provided with the
approved power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on October 26, 2020.
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 G0483 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; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not support a specific reason for requiring the definitive drug test. There is no documentation of concern noted about misuse/abuse of medications, no documentation of risk assessment score or information as to why the doctor is wanting to test for more than 22 classes of drugs.
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 G0483 provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bladder treatment provided on
November 5, 2020.
You asked the Plan to waive the copayment for the bladder treatment. You say that the nurse administered the
treatment. You say that you should pay a lower copayment for only being seen by the nurse. 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 each in-network specialist visit for Medicare-covered services.
You have been asked to pay a $35 copayment for the bladder treatment. The bladder treatment falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show you
received treatment at a specialist's office. 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 bladder
treatment provided on November 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the
enrollee on August 17, 2020, by a non-participating provider.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the services are not covered by Medicare.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. The enrollee had cardiovascular
risk assessment testing on August 17, 2020. The denial remains upheld as non-covered as Medicare denies
coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients
with suspected or documented cardiovascular disease Therefore, we decided that the Plan does not have to pay
for cardiovascular risk assessment testing provided to the enrollee on August 17, 2020, by a non-participating
provider.