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

We decided that the Plan does not have to waive the copayments for the office visits and wound care provided from November 21, 2019 to December 19, 2019.
You asked the Plan to waive the copayments for the office visits and the wound care. You say that you should not be responsible for the cost share. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $10 copayment for services obtained from a primary care provider or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a primary care provider's office and a $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital or other facility charges and physician or surgical charges. You have been asked to pay a total of $339.16 for the office visits and the wound care. The office visits fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The wound care falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment
Member Liability
November 21, 2019
Office visit
$49.64
$10.00
$10.00
December 5, 2019
Wound care
$161.18
$295.00
$159.58
December 12, 2019
Wound care
$161.18
$295.00
$159.58
December 19, 2019
Office visit
$49.64
$10.00
$10.00
Total
$339.16
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 office visits and wound care provided from November 21, 2019 to December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on
February 4, 2020.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the Plan
should pay this claim. The Plan denied your request. The Plan says there must be information in the patient's
medical record that supports the medical necessity for the item.
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. No medical records were received to support the diagnosis on the
submitted order, therefore the billed codes cannot be supported. Based on this information, we decided that
Medicare rules for coverage of the knee orthosis (L1833) and suspension sleeve (L2397) have not been met.
Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided
on February 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional occupational therapy (OT) visits.
You asked the Plan to pre-approve these services. You say that the enrollee needs to make more progress. The
Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the enrollee has increased difficulty performing activities of daily
living. The April 17, 2020 note states that he is alert and can complete upper body activities of daily living
(ADLs) with minimal assist and lower body ADLs with moderate to maximal assist. His upper body strength
has improved. The requested therapy is generally not accepted as specific and effective therapy for the patient's
condition. The records do not demonstrate that the unique skills of a professional therapist are required to
safely and effectively provide treatment, that the services can be safely and effectively performed only by a
therapist, or under the supervision of a therapist. The services are not part of a maintenance program and are
not medically necessary to maintain the enrollee's current condition or prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve 10 additional occupational therapy (OT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite - four or more surfaces, posterior (D2394) Resin-based composite - three surfaces, posterior (D2393) provided February 7, 2020.
You asked the Plan to pay for the dental services. You say that you had to get 3 fillings and your doctor said that you needed to have these filled because the teeth were rotting and it needed to be filled immediately. The Plan denied your request. The Plan says the benefit maximum has been met.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that there is a $200 allowance for fillings and simple tooth extractions every year. The enrollee has been asked to pay $377. The provider billed $577 and the plan paid the $200 allowable for the dental services. The services fall within the Dental services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to pay for resin-based composite - four or more surfaces, posterior (D2394) Resin-based composite - three surfaces, posterior (D2393) provided February 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with
suspension sleeve (L1851, L2397) provided to the enrollee on October 23, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on October 23,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit received on December 31,
2019.
You asked the Plan to waive the copayment for the office visit. You say that you would like the plan to
reconsider their decision. The Plan denied your request. The Plan says the claim has been processed correctly
per your plan benefit.
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 specialist office visits.
Review of the file shows that your maximum out of pocket had not been met at the time services were
rendered. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the
physician/practitioner 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 office visit received on December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi-electronic hospital bed with side rails (E0260).
You asked the Plan to pre-approve the semi-electronic hospital bed with side rails. You say that you have restless leg syndrome and needs to elevate your head with 2 pillows to sleep at night. Your current bed is falling apart and you need this bed to sleep. The Plan denied your request. The Plan says this is not medically necessary due to the criteria not being met.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electronic hospital bed with side rails. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that the enrollee requires positioning of the body in ways not feasible in an ordinary bed. There is no evidence that the enrollee requires special attachments that cannot be fixed and used on an ordinary bed. There is no evidence that the enrollee requires frequent and immediate changes in body position. Therefore, the documentation does not show that the requested semi-electric hospital bed is currently medically necessary or reasonable.
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 semi-electronic hospital bed with side rails have not been met. Therefore, we decided that the Plan does not have to pre-approve semi-electronic hospital bed with side rails (E0260).
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 January 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 for the medical services provided to the enrollee by an out-of-network provider on January 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 5, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for an office visit. You say that these services were recommended by the member's
primary care physician. The Plan denied your request. The Plan says no prior authorization was obtained. The
Plan says that the member's primary care physician did not refer these services.
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 an office visit provided on February 5, 2020 by an
out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve lower partial denture, resin base (D5212).
You asked the Plan to pre-approve the lower partial denture. You say that the services are needed because the enrollee's tooth is broken cracked and infected. The Plan denied your request. The Plan says that the requested service is not considered medically necessary.
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 the lower partial denture 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 the lower partial denture. Our reviewer says that this requested items/services is considered reasonable and necessary in this case. Our physician reviewer found the criteria for coverage for a mandibular removable resin base partial denture (D5212) have been met. The bone support of the remaining teeth appears adequate to support the partial. Along with the complete maxillary denture the mandibular partial would provide adequate masticatory function. 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 the lower partial denture have been met. Therefore, we decided that the Plan has to pre-approve lower partial denture, resin base (D5212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 multiple power option power wheelchair
(K0842) and accessories (E2377, E2313, E2311, E1007, E1028, E1012, E2361, E2601, E0955).
You asked the Plan to pre-approve a group 2 multiple power option power wheelchair and accessories. You say
that this is medically necessary. The Plan denied your request. The Plan says a single power option would be
sufficient.
The Plan follows Medicare rules. Medicare rules say that a Group 2 Multiple Power Option PWC is covered
only when the above listed criteria are met.
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 group 2 multiple power option power
wheelchair and accessories. Our reviewer says that the criteria for coverage of these items have not been met.
Our physician reviewer found the submitted medical records do not show that the beneficiary is at high risk for
development of a pressure ulcer and is unable to perform a functional weight shift or utilizes intermittent
catheterization for bladder management and is unable to independently transfer from the wheelchair to bed, that
the power seating system is needed to manage increased tone or spasticity, or that the beneficiary uses a
ventilator which is mounted on the wheelchair. The specific wheelchair requested is not medically necessary.
Therefore, the accessories are also not approved.
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 group 2 multiple power option power wheelchair and accessories have not
been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 multiple power option
power wheelchair (K0842) and accessories (E2377, E2313, E2311, E1007, E1028, E1012, E2361, E2601,
E0955).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc.
You asked the Plan to pre-approve these 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 records show that you have pain
related to right knee osteoarthritis confirmed via x-rays. You have tried and failed conservative treatment. You
have not tried and failed the Plan's required drugs of Synvisc/Synvisc-One, Durolane and Gelsyn-3. The
records do not support that the required drugs would be less effective or have adverse effects; therefore, the
Monovisc is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Monovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 18, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room through the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a MRI of the breast (77049) provided on December 27, 2019.
You asked the Plan to pay for the MRI. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77049 is not recognized by the Outpatient Prospective Payment System and an alternate code for the same service may be available.
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 77049 is not supported in the record. Specifically, CPT code 77049 has a status code of B. This means that CPT code 77049 is not recognized by the Outpatient Prospective Payment System when submitted on an outpatient hospital bill type. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pay for a MRI of the breast (77049) provided on December 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 5, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed
services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for
coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to
pay for the drug testing services provided on November 5, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for a pneumococcal vaccine (90670) provided on January 16, 2020.
You asked the Plan to hold you harmless for a pneumococcal vaccine. You say that you were not informed that this would not be covered. The Plan denied your request. The Plan says that this vaccine is only covered once per lifetime.
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. You were given a pneumococcal vaccine by a contract provider. The file does not show that the Plan provided notice that a pneumococcal vaccine would not be covered. Under Medicare rules, this means a pneumococcal vaccine is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for a pneumococcal vaccine (90670) provided on January 16, 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.