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

We decided that the Plan does not have to pay for the nursing facility care (99305) provided on August 6, 2019 and August 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON nursing facility care. You say that these services should be covered. The Plan denied your request. The Plan says these services were not authorized.
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 nursing facility care (99305) provided on August 6, 2019 and August 20, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe mammogram provided on December 11, 2019.You asked the Plan to waive the copayment forthe mammogram. You say that a diagnostic mammogram has been your annual mammogram for years. You say that you will stop doing mammograms if you have to pay this every year.The Plan denied your request. The Plan says the claim reprocessed to only apply a $10 copayment.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 each basic imaging service. You have been asked to pay a $10 copayment for the mammogram. The mammogram falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment forthe mammogram provided on December 11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy services.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says there is detail lacking about significant functional limitation or skills that require further intervention of physical therapy.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 the 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 a recommended course of physical therapy for your condition could be expected to include up to 24 therapy treatment sessions. Goals can usually be achieved with fewer than the number of treatments recommended. In this case, you have already had extensive post-operative physical therapy. You have functional range of motion of your hip, and you are ambulating without an assistive device. There is no residual impairment in terms of weakness or functional impairment affecting your gait. At this point, you appear to have achieved your postoperative therapy goals including being able to independently perform a home exercise program.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 pre-approve continued physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic manipulative treatment (98941) and the electric stimulation therapy (97014) provided by the out of network (OON) provider on December 2, 2019 and December 4, 2019.You asked the Plan to pay forthese services. You say that you were told by the provider's officethat they arecontracted withthe Plan.The Plan denied your request. The Plan says the services were provided by an out of network provider, without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan 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 noexception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe chiropractic manipulative treatment (98941) and the electric stimulation therapy (97014) provided by the out of network (OON)provider onDecember 2, 2019 andDecember 4, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveradiofrequency ablation.You asked the Plan to pre-approveradiofrequency ablation. 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 follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered for certain indications.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 radiofrequency ablation. Our reviewer says that the documentation does not support that the requested injection services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain which does not radiate. The enrollee had radiofrequency ablation of the Right L1-L3 on July 23, 2019 and then radiofrequency ablation of the Right L4-S1 on December 17, 2019.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rulesfor coverage of radiofrequency ablation have not been met.Therefore, we decided that the Plan does not have to pre-approveradiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for an Aflibercept injection with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are 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 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 a referral for an Aflibercept injection with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay formoderate sedation services (99152) provided on August 29, 2019.You asked the Plan to pay forthe moderate sedation services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not indicate the presence of an independent trained observer to assist in the monitoring if the patient's level of consciousness and physiological status.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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.We find that CPT code 99152 is not supported in the record. Specifically, the documentation submitted does not indicate the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met.Therefore, we decided that the Plan does not have to pay formoderate sedation services (99152) provided on August 29, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion services provided to the enrollee from November 17, 2019 to November 24, 2019 and billed under code S9328.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the code billed has an invalid status code for Medicare billing purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code billed has a status code indicator of "I" which that does not allow payment on Medicare claims.Therefore, we decided that the Plan does not have to pay forhome infusion services provided to the enrollee from November 17, 2019 to November 24, 2019 and billed under code S9328.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 15,
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 pay for the laboratory services rendered on
June 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis LT/RT (L1833) and suspension sleeve LT/RT (L2397) provided November 19, 2019.
You asked the Plan to pay for the orthoses. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says the services are not supported in the medical records received.
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 pay for the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided medical records do not contain the required documentation to support the medical necessity for the knee orthosis and suspension sleeve as defined in the Local Coverage Determination (LCD). 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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis LT/RT (L1833) and suspension sleeve LT/RT (L2397) provided November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a scooter lift for a vehicle.
You asked the Plan to pre-approve a scooter lift for a vehicle. You say that you have a scooter but no way to transport it. The Plan denied your request. The Plan says a lift for a vehicle is not primarily medical and cannot be used in the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Also, the item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a scooter lift for a vehicle.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepersonal care assistant services.You asked the Plan to pre-approvethese services. You say that you have eye nystagmus that affects your ability to drive.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.We looked at the file and Medicare rules. The services at issue are personal care assistance. These services are custodial in nature and are not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvepersonal care assistant services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forAssembly and operation of pump with oxygenator or heat exchanger (99190) provided on September 25, 2019.You asked the Plan to pay forAssembly and operation of pump with oxygenator or heat exchanger. You say that the charges are for the Perfusionist that setup and operated the heart-lung machine for this enrollee's surgery.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 CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. You provided Perfusionist services to the enrollee while inpatient status in a facility.  Payment for this service would have been included under the facility claim for inpatientservices. Payment to you for this service is the responsibility of the facility or hospital. We looked at the file and Medicare rules.Therefore, we decided that the Plan does not have to pay forAssembly and operation of pump with oxygenator or heat exchanger (99190) provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 17, 2019 by an out of network (OON) provider.You asked the Plan to pay for the office visit (99214). You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the use 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 for the medical services provided on September 17, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetopical application of fluoride varnish (D1206).You asked the Plan to pre-approvethe topical application of fluoride varnish. You say that you would like this service covered because the particular type of fluoride your dentist uses is not covered by your plan. You also say that the fluoride that the Plan covers is no longer used by the majority of dentists.The Plan denied your request. The Plan says this procedure is not listed as covered by your plan.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 rulesapply 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 pre-approvetopical application of fluoride varnish (D1206).Your complaint about the Plan falsely advertising is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for drug testing provided to the enrollee on October 3, 2019 and billed under code G0483.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says code G0483 (1 Unit) remains not supported. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed. The submitted Laboratory Requisition does not contain details of panel that was requested. The submitted documentation does not itemize what tests are included in this panel; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee. Therefore, we decided that the Plan does not have to pay for to pay for drug testing provided to the enrollee on October 3, 2019 and billed under code G0483.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202), x-ray exam of the cervical spine (72040), x-ray exam of the lumbar spine (72100), manual therapy (97140), and the radiographic procedure (76499) provided by provider from September 23, 2019 to October 14, 2019.You asked the Plan to pay for these services. You say that the provider's treatments warrant payment because the end results are significant and cost effective.The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.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 services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the office visit (99202), x-ray exam of the cervical spine (72040), x-ray exam of the lumbar spine (72100), manual therapy (97140), and the radiographic procedure (76499) provided  September 23, 2019 to October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on November 18, 2019 by an out of network (OON) provider. You asked the Plan to pay for podiatry services. You say that if you had known that the provider was out-of-network you would have not made the appointment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.
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. Please contact the Plan for a list of in-network providers available for these services. 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 podiatry services provided on November 18, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for Podiatry services (99308, 11720) provided May 18, 2019.
You asked the Plan to waive the deductible for the podiatry services. You say that you were not aware the services were provided. The Plan denied your request. The Plan says the deductible was correctly applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible for Out-of-network services. The item or service you asked the Plan to waive the deductible for falls within the benefit category Out-of-network services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for Out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the podiatry services was received on May 18, 2019. Therefore, we decided that the Plan does not have to waive the deductible for Podiatry services (99308, 11720) provided May 18, 2019.