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

We decided that the Plan does not have to pay for the office visit (99213) provided on April 21, 2021, by an out of network (OON) provider.
You asked the Plan to pay for the physician service. You say that the enrollee was seen in the hospital prior to this date of service. You say that this was a follow up visit. You say that the provider did not know what insurance the enrollee had at the time the services were provided. You also say that no authorization was obtained as this was a follow up to a hospital visit. The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee. The Plan also says that the provider should have verified the enrollee's eligibility, health benefits and obtained authorization prior to the enrollee's visit before providing services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 office visit (99213) provided on April 21, 2021, by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance transport provided on March 5, 2021. You asked the Plan to pay for the air ambulance transport. The Plan denied your request. The Plan says air ambulance service was not medically necessary for the enrollee's medical condition per Medicare.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. The transportation could have been performed in a much quicker and safer manner using ground transport since this was a trip under 10 miles and 25 minutes in duration. 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 air ambulance transport. Our reviewer says that the air ambulance transport was not medically necessary. Our physician reviewer found that emergency medical services (EMS) was contacted due to reported seizure activity, confusion. The enrollee was given Versed and a propofol drip and was transported to the emergency department. An orogastric tube insertion was unsuccessful. The enrollee was having seizures related to cerebrovascular accident (CVA) and required ambulance services. The transferring hospital appeared to not have adequate facilities for the enrollee's condition. Ground transportation was not contraindicated as the travel time was less than 30 minutes and appropriate care could have been provided via the ground ambulance. 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 air ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance transport provided on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for an extraction (D7210) provided on
November 16, 2020.
You asked the Plan to pay an additional amount for an extraction. You say that you want the Plan to pay an
additional amount towards the service. The Plan denied your request. The Plan says the claim was processed
correctly.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of an extraction have not been met. Specifically, the allowed amount of this service for an out-ofnetwork
provider was paid by the plan. Therefore, we decided that the Plan does not have to pay an additional
amount for an extraction (D7210) provided on November 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from March 26, 2021, to March 29, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you did not administer any drugs that were not given to you by the medical staff at the hospital. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B of Original Medicare.
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 pay for the self-administered drugs provided from March 26, 2021, to March 29, 2021. Benefits for the self-administered drugs 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 reimburse you for hearing aids provided on September 2, 2020.
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says members are required to contract the Plan's hearing vendor to access the benefit.
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. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on December 30, 2020, by an OON
provider.
You asked the Plan to pay for the home visit. You say that the hospital staff failed to obtain authorization and
the doctor should not be penalized. The Plan denied your request. The Plan says no prior authorization was
obtained.
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 the home visit provided on December 30, 2020, by
an OON provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay up to the allowed amount for the vertical bitewings. We decided that the Plan does not have to pay more for the comprehensive oral evaluation and periodontal maintenance.
You asked the Plan to pay more for the comprehensive oral evaluation, periodontal maintenance, and to pay for the vertical bitewings. You say that you need help covering the charges for these services. The Plan says that you are responsible for the difference between the in-network fee schedule and the dentists' charged fees when services are rendered OON.
We decided that the Plan has to pay up to the allowed amount for the vertical bitewings.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The record shows that you received vertical bitewings from an OON provider. Your 2021 EOC states that bitewing x-rays are a covered benefit. The EOC does not clearly state which types of bitewing x-rays are covered nor does the EOC list specific bitewing x-ray codes that are covered. You reasonably believed the vertical bitewings you received would be covered because bitewing x-rays are listed as a covered benefit. Therefore, we decided that the Plan has to pay up to the allowed amount for the vertical bitewings.
We also decided that the Plan does not have to pay more for the comprehensive oral evaluation and periodontal maintenance.
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, you are responsible for the difference between the billed amount and allowed amount for dental services received OON. Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation and periodontal maintenance.
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 wrist-hand orthosis (L3908) provided to the enrollee on February 25, 2021.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.
The plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment on November 22, 2019. This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for wrist-hand orthosis (L3908) provided to the enrollee on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the 2018 Wellness Allowance benefit.
You asked the Plan to reimburse you for the 2018 Wellness Allowance benefit. The Plan denied your request.
The Plan says the deadline to request reimbursement for year 2018 was until March 31, 2019.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan received your reimbursement request for
the Wellness Allowance on December 31, 2020, which was beyond the timeframe. Therefore, we decided that
the Plan does not have to reimburse you for the 2018 Wellness Allowance benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for exercise equipment (A9300) purchased on October 6, 2020.
You asked the Plan to pay for exercise equipment. You say that you do not see yourself returning to a gym in
the near future so you believe that the equipment should be reimbursed. The Plan denied your request. The Plan
says you have already been reimbursed for your gym membership in March 2020 thereby exhausting the
wellness allowance.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan will temporarily
allow your Wellness Allowance to reimburse you for exercise equipment purchased October 1, 2020, to
December 31, 2020.
The Plan's rules for coverage of exercise equipment have not been met because you had already exhausted
your $150 Wellness Allowance in March 2020 prior to purchasing the exercise equipment. Therefore, we
decided that the Plan does not have to pay for exercise equipment (A9300) purchased on October 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on February 26, 2021 and
March 5, 2021.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says termination
 was received with the appeal; however, the member began primary coverage with
UMR starting on January 1, 2021. Until the explanation of benefits (EOB's) from UMR are received, these
claims are processed correctly and will be upheld.
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 has upheld the
denial of payment of the claims. As the secondary insurer, the Plan cannot be held responsible for the
ambulance services until the primary insurer has denied the claim for these services. Therefore, we decided that
the Plan does not have to pay for ambulance services provided on February 26, 2021 and March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on June 1, 2020.
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 was rendered 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 had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on June 1,
2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on February 8, 2020.

You asked the Plan to pay for an x-ray. You say that the timely filing limit should be waived due to the public health crisis. The Plan denied your request. The Plan says this claim was filed more than a year after the service was provided.

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 an x-ray was not filed until April 2, 2021. 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 an x-ray (71045) provided on February 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the POV, group 1 standard, patient weight capacity up to and including 300 pounds (CPT Code K0800).
You asked the Plan to pre-approve the POV. You say that you do not need a scooter in the house. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the POV have not been met. The information provided to us from your physician indicates that the POV is exclusively for use in the community. Based on this information we are not able to approve this request at this time. Therefore, we decided that the Plan does not have to pre-approve the POV, group 1 standard, patient weight capacity up to and including 300 pounds (CPT Code K0800).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider on January 22, 2021.
You asked the Plan to pay for the hearing aids. You say that you were told insurance would pay $2,500 each for both. You say that you were not told you had to file the claim with the Plan provider. The Plan denied your request. The Plan says hearing aids ordered through providers other than Plan providers 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 they are received from a Plan provider. We looked at the case file and the Plan's rules. 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 the hearing aids provided by an out-of-network provider on January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory viral panel (87498, 87502, 87503, 87634, 
87798) provided on March 8, 2021. 
 
You asked the Plan to pay for a respiratory viral panel. You say that these tests were ordered by the referring 
physician. The Plan denied your request. The Plan says these tests were 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. 
 
We find that CPT codes 87498, 87502, 87503, 87634, and 87798 are not supported in the medical record. 
Specifically, the record shows that these codes were used to report tests that were performed as part of a multi-
target respiratory viral panel. There are a more appropriate codes used to report multi-target respiratory viral 
panels. Based on this information, we decided that Medicare rules for coverage of a respiratory viral panel have not 
been met. Therefore, we decided that the Plan does not have to pay for a respiratory viral panel (87498, 87502, 
87503, 87634, 87798) provided on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection.
You asked the Plan to pre-approve the requested service. You say that a more specific injection to the nerve root may provide improved relief. The Plan denied your request. The Plan says there is no documentation why a repeat injection should be done.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The records show that lumbar epidural steroid injections for left L5 andS1 were requested. We looked at the file, and Medicare rules. The records show that the enrollee received only a 30% relief from pain for a short duration.
There should be at least 6 weeks of pain relief (defined as at least a 50% reduction in pain) in order to conclude that a diagnostic injection is efficacious. 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 pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the epidural steroid injections provided on March 3, 2021.
You asked the Plan to pay for the injection services. The Plan denied your request. The Plan says the documentation does not support two units being provided.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 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 the injection services. Our reviewer found that the records show the injections were given at C5 - C6 and C6 - C7 bilaterally. The services were not reported with a valid modifier indicating a bilateral procedure. Therefore, 2 units for each code would not be covered.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the epidural steroid injections provided on March 3, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from November 29, 2020, to December 2, 2020 and billed under code G0299.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says this code has a status indicator of "I" which excludes payment on Medicare claims. Medicare uses another code for reporting or payment of these services.

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 reported is not allowed on Medicare claims. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from November 29, 2020, to December 2, 2020 and billed under code G0299.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve a home health aide. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 a home health aide. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee does not have any 
documented skilled nursing or skilled therapy needs. 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 home health aide have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide services.