Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) received December 2, 2019 from the out-of-network provider.
You asked the Plan to pay for the dental services. You say that you received partial reimbursement for services you received in 2020, but not for the same services received in 2019. The Plan denied your request. The Plan says in 2019 services performed by an out-of-network dentist were not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. In 2019 the Plan did not offer coverage for dental services received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) received December 2, 2019 from the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0823).
You asked the Plan to pre-approve a group 2 power wheelchair. You say that this device is medically necessary. The Plan denied your request. The Plan says rules for a power operated vehicle have not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0823).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pharmacogenetic testing provided on October 27, 2020.
You asked the Plan to pay for the services provided. You say that the pharmacogenetic testing can affect clinical decisions. The Plan denied your request. The Plan says that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The services at issue are pharmacogenetic testing. The rules the Plan used in their decision to deny services are not binding in this case. The Local Coverage Determinations and Article (L36523 and A57559) do not have Part B jurisdiction where the services were provided. The rules for a cardiovascular risk assessment are not applicable in this case. Furthermore, the enrollee was referred for the testing at issue by a contract provider. The file does not show that the Plan provided notice that the testing would not be covered. Under Medicare rules, this means the services are considered approved by the Plan. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the pharmacogenetic testing provided on October 27, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic continuous glucose monitor supply allowance
provided on December 4, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor supply allowance. You say that the
Plan should pay this claim. The Plan denied your request. The Plan says the physician order states no insulin
treatment.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections or by pump. Based on this information, we decided that Medicare rules for
coverage of the therapeutic continuous glucose monitor supply allowance have not been met. Therefore, we
decided that the Plan does not have to pay for therapeutic continuous glucose monitor supply allowance
provided on December 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ECG and ultrasounds provided on
August 28, 2020.
You asked the Plan to waive the copayments for an ECG and ultrasounds. You say that you feel that the claims
were processed incorrectly with a higher cost-sharing benefit. The Plan denied your request. The Plan says the
claims were processed correctly, and you are being charged the correct 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 $30
copayment for non-radiological diagnostic services and a $160 copayment for each ultrasound.
You received an ECG on August 28, 2020. Therefore, you are responsible to pay the allowed amount of
$14.13, which is less than the $30 copayment.
You received two ultrasounds on August 28, 2020. Therefore, you are responsible to pay a $160 copayment per
each ultrasound. The total amount you owe for ultrasounds is: $160 (copayment) x 2 (ultrasounds) = $320.
The total amount you owe is: $14.13 + $320 = $334.13.
You have been asked to pay the total copayment amount of $334.13 for an ECG and ultrasounds. An ECG and
ultrasounds fall 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 copayments for an ECG and ultrasounds provided on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on August 22, 2020.

You asked the Plan to pay for an office visit. You say that the enrollee was seen for a psychiatric consultation while in the emergency department.The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code. 

In this case, the CPT Code Manual definition of code 99203 is office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.

We find that CPT code 99203 is not supported in the medical record. Specifically, this visit took place in the emergency department and was not billed with an emergency department visit code.Based on this information, we decided that Medicare rules for coverage of an office visit have not been met.Therefore, we decided that the Plan does not have to pay for an office visit (99203) provided on August 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the alveoloplasty not in conjunction with extractions (D7321) provided on January 18, 2021.

You asked the Plan to pay for the alveoloplasty. You say that you believe this service should be covered.The Plan denied your request. The Plan says this service is not covered under 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 rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the alveoloplasty not in conjunction with extractions (D7321) provided on January 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment provided on May 25, 2020.
You asked the Plan to pay for the ambulance response and treatment. You say that you were not physically in the ambulance and were unaware you would be charged if you didn't get in the ambulance. The Plan denied your request. The Plan says prior authorization for out-of-network services was not requested.
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 on May 25, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment provided on May 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair (K0001).
You asked the Plan to pre-approve a manual wheelchair. You say that the enrollee's wheelchair was stolen in January. The Plan denied your request. The Plan says the documentation does not support that another wheelchair is necessary at this time.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a manual wheelchair. Although you state that the enrollee's wheelchair was stolen in January, this is not noted in the medical records or in any submitted documentation. Records dated March 23, 2021 note that the enrollee currently uses a wheelchair. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (K0001).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on July 13, 2020, to October 31, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that because of Covid-19 you could not travel. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 July 13, 2020, to October 31, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compressor and appliance provided on November 6, 2020.
You asked the Plan to pay for the pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and Segmental pneumatic appliance for use with pneumatic compressor, full arm (E0668). You say that the pneumatic compressor and appliance were medically necessary. The Plan denied your request. The Plan says the documentation did not sufficiently document the enrollee's need or medical condition to support the medical necessity for the billed supply code.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery or relevant medical records which support medical necessity for the supplies provided in this case. The documentation submitted did not include an itemized shipping/billing invoice or proof of delivery indicating the specific supplies dispensed. The record shows that the Plan made several attempts to obtain the necessary documentation without success. The medical record does not mention lymphedema or support medical necessity of the pneumatic compressor. Therefore, we decided that the Plan does not have to pay for the pneumatic compressor and appliance provided on November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that you need these dentures to be approved for coverage. The Plan denied your request. The Plan says these services are allowed one time every 60 months. The Plan also says that you received these services less than 60 months ago.
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, dentures are limited to one maxillary denture and one mandibular denture per 60 months. The record shows that you received an immediate maxillary denture (D5130) and a mandibular partial denture (D5226) on July 28, 2020 and your maxillary and mandibular denture benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) and an implantable
neurostimulator electrode.
You asked the Plan to pre-approve a SCS and an implantable neurostimulator electrode. 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 follows Medicare rules. Medicare rules say that SCS may be covered for the relief of chronic
intractable pain under specific circumstances.
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 SCS and an implantable
neurostimulator electrode. Our reviewer says that the services are not medically necessary. Our physician
reviewer found you have not had a psychological evaluation. You do not have an evidence-based indication for
a SCS trial. The request is deemed not medically reasonable or 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 a SCS and an implantable neurostimulator electrode have not been met.
Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) and an
implantable neurostimulator electrode.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic radiology services provided by a participating provider on December 10, 2020.
You asked the Plan to waive the copayment for a duplex scan. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient diagnostic tests/radiological diagnostic services. You have been asked to pay a $150 copayment for a duplex scan. The correct copayment has been applied to the services that were provided. A duplex scan falls within the outpatient diagnostic tests/radiological diagnostic 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 diagnostic radiology services provided by a participating provider on December 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services described by current procedural terminology (CPT) code 88342 provided on December 3, 2020.
You asked the Plan to pay for CPT code 88342. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says CPT code 88342 is a component of CPT code 17311.
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, we have confirmed that code CPT code 88342 has a bundled relationship with code 17311 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services described by current procedural terminology (CPT) code 88342 provided on December 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, spine, lumbosacral (72100) provided September 14, 2019.
You asked the Plan to pay for the diagnostic services. You say that the following documentation is being submitted to support the medical necessity of the procedure performed. Radiology reports are enclosed for your review. The Plan denied your request. The Plan says the plan did not receive the primary carrier's Explanation of Benefits.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan is the secondary insurance. As the secondary insurer, the Plan cannot be held responsible for the diagnostic services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the radiologic examination, spine, lumbosacral (72100) provided September 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.
You asked the Plan to pre-approve Ondansetron. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.
Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750), and a post and core in addition to a crown, indirectly fabricated (D2952) for tooth # 31.
You asked the Plan to pre-approve the dental services. You say that you feel you should be able to do what you need done with the $500 allowance per year. You say that you need a root canal and crown done which costs $1,000. You also say that you do not understand why $500 cannot be applied to these services. The Plan denied your request. The Plan says crown is not listed as a covered service. The Plan says that post and core in addition to a crown is not listed as a covered service either.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750), and a post and core in addition to a crown, indirectly fabricated (D2952) for tooth # 31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom G7 continuous glucose monitor.

You asked the Plan to pre-approve the Dexcom G7 continuous glucose monitor. You say that this device is medically necessary. The Plan denied your request. The Plan says this device has not been approved.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.

The file shows that the enrollee has a Dexcom G6 continuous glucose monitor. Dexcom G6 continuous glucose monitor serves the same purpose as the Dexcom G7 continuous glucose monitor. Therefore, we decided that the Plan does not have to pre-approve the Dexcom G7 continuous glucose monitor.