Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thirty-nine (39) additional Logisticare miles.

You asked the Plan to pre-approve additional Logisticare miles. You say that you are in need of transportation to the doctor to receive much needed knee replacement surgery and have been waiting two years and will become crippled without surgery. The Plan denied your request. The Plan says you have exceeded your benefit limit.

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. We looked at your request, the records in the case file, and the rules. The 51st mile and beyond is not a covered benefit. The health plan contract says Up to forty-eight (48) one-way trips are covered per calendar year (limited to ground transportation only). Each one-way trip must not exceed fifty (50) miles of driving distance. A trip is one-way transportation; a round trip is two (2) trips. Therefore, the requested thirty-nine (39) additional Logisticare miles are not approved because you have exceeded your benefit limit with the request. Therefore, we decided that the Plan does not have to pre-approve thirty-nine (39) additional Logisticare miles.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that the referring 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 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 lab work provided on October 26, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a failure of conservative therapy.
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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal evidence of marked hyperkeratosis with hyperplasia and hyperpigmentation, papillomatosis cutis lymphostatica, deformity of elephantiasis, skin breakdown with persisting lymphorrhea, detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a likely etiology, and objective documentation of an actual four week trial with regular and compliant use of an appropriate compression bandage system or compression garment to provide adequate graduated compression. There should be detailed measurements over time indicating the presence of lymphedema and response to treatment. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care, per day (99222).

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not payable as the claim was submitted untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for this service was not filed until October 6, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the initial hospital care, per day (99222).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve dialysis. You say that you would like approval for this continuation of care. The Plan denied your request. The Plan says there are in-network providers available 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 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 dialysis to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services received on August 6, 2020.
You asked the Plan to pay for the eye refraction services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover eye refractions. We looked at the file and the Plan's rules. The Plan does not cover eye refractions. While you do have a surgical and non-surgical need for eyewear or contact lenses benefit of $200 annual allowance, that allowance is specifically for eyewear or contacts, not any services related to the eyewear or contacts. Based on this information, we decided that the Plan's rules for coverage of the eye refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction services received on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on August 31, 2020.
You asked the Plan to pay for these services. You say that the doctor's office told you that the services would be covered. The Plan denied your request. The Plan says the services are not covered when billed by a chiropractor.
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 service at issue is not manual manipulation of the spine. The file shows that the provider billed procedure code 99201 (office visit). These services are not covered when billed by a chiropractor. Therefore, we decided that the Plan does not have to pay for the office visit rendered on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the complete series x-ray (D0210), and the fillings for teeth # 23 and 25 provided on November 13, 2020.
You asked the Plan to pay for the dental services. You say that you think that the oral exam should be covered. You say that you it had to be done to determine what was wrong. You say that it includes bitewing x-rays so you feel that should be covered too. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says complete series x-ray is not listed as a covered service. The Plan says there is a $200 allowance for fillings and simple tooth extractions every year. The Plan also says that the $200 allowance has been exhausted.
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 limited oral evaluation and complete series x-ray are not among those covered under this benefit. Additionally, the $200 allowance for fillings and simple extractions has been exhausted.
CPT Code (tooth #)
Allowed Amount
Plan Paid
Your Responsibility
D2330 (#24)
$166
$166
$0
D2330 (#25)
$166
$34
$132
D2332 (#23)
$222
$0
$222
TOTAL:
$200
$544
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the complete series x-ray (D0210), and the fillings for teeth # 23 and 25 provided on November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve selective internal radiation therapy (SIRT) to be
provided by an OON provider.

You asked the Plan to pre-approve SIRT 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
selective internal radiation therapy (SIRT) to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Myomo/MyoPro orthosis.

You asked the Plan to pre-approve these services. You say that the orthosis will change your quality of life.
The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you have a
history of left-sided weakness. The requested Myomo/MyoPro prosthesis is not proven to be more beneficial to
treat your condition than available standard therapy. The services are not considered to be the standard of care
and are experimental/investigational in nature. The services are therefore 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 a Myomo/MyoPro orthosis.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound performed on September 18, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The records show that you had an ultrasound for a lump on your right breasts on September 18, 2020. The services rendered was diagnostic and not preventative. You were asked to pay a $20 copayment for the ultrasound. According to your health plan benefits, you are covered for Ultrasound radiology services under your Outpatient diagnostic tests with a copayment amount of $20. 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 ultrasound performed on September 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health aide services billed.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code G0156 is services of home health/hospice aide in home health or hospice settings, each 15 minutes.

We find that CPT code G0156 is not supported in the medical record. The records provided do not include home health services on the date of service at issue. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for home health aide services billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the preadmission services, COVID-19 testing (80930).

You asked the Plan to pay for the preadmission services. You say that please review claim as COVID testing was done prior to procedure, as it is required to do so before any procedure is performed. The Plan denied your request. The Plan says this service does not meet preadmission bundling requirements.

In this case, providers are only allowed 3 days prior to and including the date of admission for preadmission services. Preadmission services performed more than 3 days prior will deny. The enrollee converted to inpatient. Therefore, this date of service is beyond the 3-day payment window allowed. The provider needs to submit a corrected claim. Based on this information, we decided that Medicare rules for coverage of the preadmission services have not been met. Therefore, we decided that the Plan does not have to pay for the preadmission services, COVID-19 testing (80930).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transport.

You asked the Plan to pay for the non-emergent ambulance transport. The Plan denied your request. The Plan says there was not a prior authorization in place for this ambulance transportation and the in-network facility where you were seen for emergency room services did not order the transport.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

We looked the file, the Plan's rules and the Medicare rules. The file shows that the ambulance transport was not authorized by the Plan and the facility did not order the transport. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on September 24, 2020.
You asked the Plan to pay for the extraction. You say that an extraction (D7210) was performed, and you
would like the code corrected and processed for payment. The Plan denied your request. The Plan says the
procedure code billed is no longer valid. The Plan also says that a corrected claim can be submitted with a valid
procedure code for claim reconsideration.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We looked at the file and Medicare rules. Although you have indicated this was an error, and meant to be
coded as D7210, a corrected claim would need to be submitted with the valid code. Based on this information,
we decided that Medicare rules for coverage of the extraction have not been met. Therefore, we decided that
the Plan does not have to pay for the extraction provided on September 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for home health services provided to the enrollee from January 13, 2020, to March 11, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the claim was not submitted with the appropriate required codes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes, and for home health care claims, they must be entered in the appropriate sequence to determine payment.
In this case, the claim submitted does not include the appropriate codes. Any claim with incomplete, missing, or invalid information for all the required elements will be returned as un-processable. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for to pay for home health services provided to the enrollee from January 13, 2020, to March 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Padcev and Ondansetron HCL (J9177, J2405).

You asked the Plan to pre-approve Padcev and Ondansetron HCL. You say that these drugs are medically necessary for the enrollee's cancer. The Plan denied your request. The Plan says these drugs are not being prescribed for a medically-accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Padcev and Ondansetron HCL. Our reviewer says that the requested drugs are not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the use of these requested drugs is not FDA approved for the enrollee's condition. In addition, the use of these drugs for the enrollee's cancer is not supported in any of the CMS approved compendia.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Padcev and Ondansetron HCL have not been met. Therefore, we decided that the Plan does not have to pre-approve Padcev and Ondansetron HCL (J9177, J2405).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the copayment for the cortisone injection of large joint or joint capsule (20610).

You asked the Plan to waive or reduce the copayment for the cortisone injection service. You say that you think this procedure must have been coded wrong and you did not even stay overnight. The Plan denied your request. The Plan says this service is considered a surgical procedure. Outpatient surgical services are subject to a $325 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 $325 copayment for outpatient surgery and other medical services.

You have been asked to pay a $325 copayment for the cortisone injection service. This injection service falls within the outpatient surgery and other medical 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 or reduce the copayment for the cortisone injection of large joint or joint capsule (20610).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and supplies.

You asked the Plan to pay for the ambulance service and supplies. You say that the ambulance came but did not transport you. The Plan denied your request. The Plan says ambulance services without a transport are not covered by Medicare or the Plan and supplies cannot be charged separately.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Code A0999 is an invalid code for Medicare purposes and cannot be billed separately. Medicare rules say all services and supplies provided during an ambulance transport are covered under one billing code and each service and/or supply cannot be billed separately. Therefore, we decided that the Plan does not have to pay for the ambulance service and you are not responsible for payment of the supplies.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the stress test.

You asked the Plan to waive the copayment for the stress test. You say that you thought the stress test would be paid. You say that you have no money to pay this. The Plan denied your request. The Plan says the claim reprocessed to only apply one 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 $110 copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine, and stress tests).

You have been asked to pay a $110 copayment for the stress test. The stress test 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 for the stress test.