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

We decided that the Plan does not have to waive the copayment for the debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less (11042) provided October 2, 2020, October 16, 2020, and October 30, 2020.
You asked the Plan to waive the copayment for the debridement, subcutaneous tissue. You say that you thought you would only have a $35 copayment per service. The Plan denied your request. The Plan says the copayments have been applied correctly to your services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per visit for an outpatient surgery or procedure that you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury.
You have been asked to pay a total of $750 ($250 copayment for each date of service) for the debridements, subcutaneous tissue. This service falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less (11042) provided October 2, 2020, October 16, 2020, and October 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81479) provided on February 9, 2021.
You asked the Plan to pay for laboratory services. You say that this is covered testing. The Plan denied your request. The Plan says the documentation does not support the billing of this testing.
The Plan must follow Medicare rules. Medicare rules say that as a general rule, the Date of Service (DOS) for Clinical Laboratory and Pathology tests or services must be the date the specimen was collected. In the case of a test/service performed on a stored specimen, if a specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service must be the date the specimen was obtained from storage. We looked at the file and Medicare rules. The testing at issue was billed with a DOS of February 9, 2021. However, the records show that the specimen was collected on January 23, 2020, and received by the laboratory on January 28, 2021. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81479) provided on February 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on March 9, 2021.
You asked the Plan to pay for SNF care. You say that the hospital staff recommended SNF care. The Plan denied your request. The Plan says the denial of payment for this SNF care is correct. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. You did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. You did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99205) annual wellness visit (G0439) advance care planning (99497) provided on April 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that this treatment was medically necessary as to not compromise the enrollee's health and well-being and does concur with the Plan's current policy. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered. 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 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 outpatient office visit (99205) annual wellness visit (G0439) advance care planning (99497) provided on April 1, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you need additional transportation to get to dialysis and other appointments. You say that you are a double amputee with both legs amputated and it is difficult to drive. The Plan denied your request. The Plan says you have exhausted the number of transportation trips for this year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 11, 2021.
You asked the Plan to pay for drug testing services. You say that the drug testing services should be paid for. The Plan denied your request. The Plan says the documentation does not support 22 or more drug classes for G0483 on the date of service.
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 says this drug testing code must include 22 or more drug classes tested to qualify. We asked our coder 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 drug testing services. Our reviewer says that the service is not medically necessary.
Our reviewer found there was no abnormal initial drug screening test to suggest a need for a follow-up definitive drug test. Also, there was no indication that as many as 22 or more drug classes were applicable to this patient's clinical history and risks. Therefore, without sufficient support made for this request, the definitive drug testing, 22+ drug classes, will be considered not medically necessary. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of drug testing 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 March 11, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on February 2, 2021.

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 coverage criteria has not been met.

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 (99214) provided on February 2, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.
You asked the Plan to pre-approve Entyvio. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 Entyvio. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on March 9, 2021.
You asked the Plan to pay for the hearing aids. You say that the member will significantly benefit from the hearing aids. The Plan denied your request. The Plan says hearing aids ordered through a provider other than the Plan's hearing aid provider are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered through the Plan's hearing provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the Plan's hearing provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lead wires and electrodes rendered on November 4, 2020.
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 are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of P are bundled/excluded codes. We looked at the file and Medicare rules. Billed procedure codes A4556 (electrodes, pair) and A4557 (lead wires, per pair) have a status indicator of P and no separate payment. Therefore, we decided that the Plan does not have to pay for the lead wires and electrodes rendered on November 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety and efficacy of bone marrow aspirate for use as bone graft. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is needed. The Plan denied your request. The Plan says the benefit has been exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 10 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a programming device evaluation (93284) provided on May 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the programing device evaluation. You say that this service was necessary and provided in good faith. The Plan denied your request. The Plan says generally, out-of-network services are not covered by the Plan. There is no documentation that the service at issue was urgent or emergent, nor was it pre-approved. There is also no referral on file for this service. Therefore, payment is denied.
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 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 a programming device evaluation (93284) provided on May 6, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient speech, physical and occupational therapy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve outpatient speech, physical and occupational therapy to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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
outpatient speech, physical and occupational therapy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve proton beam radiotherapy (PBRT) for treatment of prostate cancer.
You asked the Plan to pre-approve the PBRT. You say that this is a proven treatment approach which would be best for this enrollee. The Plan denied your request. The Plan says that a review of the literature indicates that Proton Beam Radiation Therapy is not the standard of care for prostate cancer.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 PBRT. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the theoretical advantage of proton beam radiotherapy (RT) is in its dose distribution. Proton beam therapy thus permits the delivery of high doses of RT to the target volume while limiting the "scatter" dose received by surrounding tissues. Use of proton beam RT is expanding as more proton beam treatment centers open. However, there are no randomized trials comparing proton beam therapy with photon therapy or brachytherapy in men with clinically localized prostate cancer. A systematic review of the available evidence from American Society for Radiation Oncology (ASTRO) on efficacy and toxicity concluded that outcomes were similar with proton beam therapy and intensity-modulated radiation therapy (IMRT) using photons but did not demonstrate a benefit for the proton beam approach. The National Comprehensive Cancer Network (NCCN) Panel believes no clear evidence supports a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. Conventionally fractionated prostate proton therapy can be considered a reasonable alternative to x-ray-based regimens at clinics with appropriate technology, physics, and clinical expertise. This particular patient has high risk prostate cancer with a Gleason score of 7. He suffered from recurrent urinary tract infections after transurethral resection of the prostate, which indicates that brachytherapy would not be appropriate treatment in this case. As such, the use of proton beam therapy is reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PBRT have been met. Therefore, we decided that the Plan has to pre-approve proton beam radiotherapy (PBRT) for treatment of prostate cancer. 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 pre-approve the office visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visits. You say that the enrollee believes this provider's level of concern, empathy, and bedside manner will help the enrollee. The Plan denied your request. The Plan says the provider is out-of-network
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network (OON) provider.
Your complaint about in-network providers neglected the enrollee's needs 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.